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  1. 1. SwindonAcademySixthForm 1 PSYA4 Phobias Revision Notes Clinical characteristics of the chosen disorder a) Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). b) Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. c) The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent. d) The phobic situation(s) is avoided or else is endured with intense anxiety or distress. e) The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. f) In individuals under age 18 years, the duration is at least 6 months. g) The phobia is not better accounted for by another mental disorder such as OCD Issues surrounding the classification and diagnosis of their chosen disorder, including reliability and validity Reliability  Opinion of the clinician – one doctor may think that a symptom is clinically significant while another may not.  ICD-10 and DSM-IV and quite similar but differ on some of the clinical characteristics. If a patient is diagnosed by a doctor using ICD-10 they may not be diagnosed by a doctor using DSM-IV Validity  Fear is a normal adaptive response. Should such a response be medicalised and given a label?  Shyness is a normal, acceptable personality trait. Someone that is very shy might be misdiagnosed as having a social phobia.  Cultural variations. Different cultures may have different fears, for example the phobia TKS (fear of offending people) is recognised in Japan but not in other countries.  There as some similarities with other mental disorders which could mean that a patient could be diagnosed with phobia disorder when they have personality disorder. This could mean they receive the wrong type of treatment and their condition could worsen. Example paragraphs Validity
  2. 2. SwindonAcademySixthForm 2 Different Diagnostic Criteria: Phobia diagnosis can be done using the ICD-10 or the DSM-IV. Both of these medical manuals contain very similar diagnostic criteria for phobias. However, they differ in terms of the clinical characteristics for agrophobia. In the DSM-IV, if a person with agrophobia suffers four or more panic attacks, then their diagnosis would change to ‘panic disorder’. In the ICD-10, for someone to be diagnosed with panic disorder, they need to have at least 2 symptoms (one of which could be 4 or more panic attacks). This is an issue because someone’s diagnosis can actually affect what treatment they receive. Someone with a DSM diagnosis of ‘panic disorder’ may receive different treatment to someone who is agrophobic, even though they may have both been given the same diagnosis if the ICD-10 was used instead of the DSM-IV. Medicalisation of normal behaviour: Critics of the medical model have criticised diagnosing people with phobias, as they say that fear and avoidance are normal human behaviours and shouldn’t be labelled as abnormal. An issue with medicalising normal behaviour is that people get given the label of having a ‘mental illness’ which can lead to stigmatisation. Reliability Co-morbidity: Phobias often occur alongside other disorders. Sometimes it is difficult to distinguish between two disorders as one may mask the other. Randall found that 20% of people being treated for alcohol disorders had a social phobia. This is an issue as being unable to identify a social phobia in these cases could actually make the alcohol disorder worse, as people may drink as a way to avoid social phobias that bring them fear. Cultural issues: Different cultures may have different social norms which can affect the diagnosis of a phobia. In Japan, there is a common social phobia called ‘ Taijin Kyofusho’ which is the fear of offending or harming people in a social situation. In Inuit societies there is a specific phobia called ‘Kayak Angst’ which is the fear of being stranded alone in the middle of the Antarctic Ocean. This is an issue as a person living in the UK with this particular phobia may not be diagnosed as they may not meet the clinical characteristics that have been written with Western values in mind. Subjectivity: Another issue of reliability is the differences between the subjective opinions of the clinicians who are actually making the diagnosis. Some of the clinical characteristic could be said to be ‘abstract concepts’ that don’t have a concrete meaning. For example the phobia must ‘interfere significantly with a person’s normal routine’ to be diagnosed. One doctor may have a different opinion on what ‘significantly interfering’ looks likes, compared with another. This means that one person could get diagnosed by one doctor and not by another.
  3. 3. SwindonAcademySixthForm 3 Biological explanations of their chosen disorder, for example, genetics, biochemistry The genetic explanation suggests that:  Family and twin studies show phobias are at least partly caused by innate factors.  People inherit phobias from their parents, through genes.  Phobic people are more likely to have close relatives with phobias than non-phobic people. Perhaps all humans have inherited, through natural selection, a tendency to fear certain potentially dangerous things e.g. heights.  Seligman argues this is because long ago people who did not fear and avoid them, died – so their genes were not passed on.  Solyom found that 45% of phobic patients had at least one relative with the disorder, compared with 17% of non-phobic controls Genetic Factors Family studies: Fyer (1990) Interviewed 49 first-degree relatives of people with specific phobias. 31% of relatives were also diagnosed with phobias, but only two people had the same phobia. Example PEEL P: One study that supports the notion that phobias have a genetic basis is Fyer (1990) E: Fyer found that 31% of first-degree relatives of a phobic person also had a diagnosis of a phobia E: This shows that phobias are more common amongst first degree family members who share 50% of the same genetic material than what is typical for the average population. L: This therefore strengthens the biological explanation of phobias as there is evidence to support it +Supports biological explanation - Could be environmental factors as families have similar upbringings etc. - Small sample therefor can’t generalise - only two had the same phobia – you would expect a higher amount if genetic Twin Studies: Skre (2000) Looked at 23 pairs MZ twins and 38 pairs of DZ twins. Found a higher concordance (both had phobia) rate for phobias in MZ twins than in DZ twins. +Supports biological explanation -Small sample - Could be environmental factors as identical twins are treated very similar – more similar than DZ twins - few studies have been done and some contradict each other Kendler studied 1200 twins and found a much higher concordance rate in MZ twins than DZ twins + supports biological explanation +large sample so more easily generalised
  4. 4. SwindonAcademySixthForm 4 Biochemical Factors GABA Hypothesis In normal people: GABA is released automatically when people are anxious. GABA binds to GABA receptors causing the excited neurons to be inhibited. This reduces arousal and the feelings of anxiety. Some people have a dysfunction and GABA isn’t produced. This prevents excited neurons from being inhibited and so anxiety levels stay high. BZ’s increase the activity of GABA Kahn (1986) found that BZ’s were more effective than a placebo in reducing anxiety +supports bio explanation - ethical issues: deception, protection from harm etc. Biological therapies for phobias, including their evaluation in terms of appropriateness and effectiveness Anti-anxiety drugs – Benzodiazepines (e.g. Valium): are used to reduce anxiety by increasing the activity of GABA. Kahn found that BZ’s were more effective than a placebo in reducing anxiety +supports effectiveness of bio treatments - ethical issues: deception, protection from harm etc. -Turner found no difference a treatment group and a placebo group. - this weakens the strength of biological treatments as an effective treatment for phobias -ethical issues, deception, protection from harm Antidepressants – SSRI’s (Prozac) SSRI’s block the re-uptake of serotonin. This means that there is more serotonin available to excite neighbouring brain cells. Liebowitz found that SSRI’s were more effective than a placebo in reducing anxiety +supports effectiveness of bio treatments - ethical issues: deception, protection from harm etc. Papakostas meta-analysis of SSRI studies and found that there was significant difference between treatment groups non-treatment (control) groups -This reduces the support for the idea that drugs are an effective treatment for phobias +meta-analysis so looks at lots of data -can’t ensure validity as they didn’t conduct the research themselves Appropriateness of treatment + quick and cost-effective +can allow patients to access other forms of treatment e.g. some social phobia may prevent them attending CBT sessions - Dangers of dependence: people may become addicted to the drugs and then still have the phobia when taken off the mediation
  5. 5. SwindonAcademySixthForm 5 - Treats the symptoms not the cause. As soon as drugs treatment stops then may still have the phobia. -Ethical issues. Should be people medicated for something that some people consider personality traits e.g. shyness. - side effects: increased aggression and long-term memory impairment. Psychological explanations of phobias, for example, behavioural and psychodynamic Psychodynamic: a phobia is a conscious expression of repressed conflict Freud Case study of Little Hans: Fear of horses was a conscious expression of his inner conflict. His inner conflict was being scared of castration and scared of his mum leaving him. + supports psychodynamic + case study so rich data - case study so can’t be generalised - could be explained by learning theory e.g. associated horse falling over with fear -limited evidence – only one study -lack of objectivity – based on fathers account and one observation by Freud. Learning Theory: This theory assumes that all behaviour is learnt through conditioning or modelling. Classicalconditioning, fear is acquired when an individual associates a neutral stimulus (a white rat) with a fear response. Watson and Rayner Little Albert. UCS (Loud noise) paired with CS (Rat) to produce CR + supports classical conditioning - unethical as Albert was not protected from harm, wasn’t given the right to withdraw, didn’t give consent -case study so can’t generalise - temporal validity. Almost 100 years ago. A small child nowadays may be more familiar with some of the objects used so may not have has the same fear response. Ohman: pictures of dangerous and non-dangerous objects were paired with electric shocks. It took 1 pairing to condition the dangerous objects and 5 pairings to condition the non-dangerous pairings +supports classical conditioning -lab based -Ethics – protection from harm Operant conditioning – Mowrer proposed that it involves more than just classical conditioning. He said that it is first classicalconditioning but that avoiding a phobic stimulus reduces fear and is therefore reinforcing (operant conditioning)
  6. 6. SwindonAcademySixthForm 6 Modelling: observing behaviour, remembering it, having the opportunity to copy it and being motivated to copy it. Bandura: Participants watched a confederate act in pain when a buzzer sounded. Participants then experienced the fear response when the buzzer sounded. +supports modelling and learning theory - unethical - demand characteristics Cognitive Individuals who suffer from mental disorders have distorted and irrational thinking – which may cause maladaptive behaviour. ‘Faulty thinking’ is the way you think about the problem rather than the problem itself which causes the mental disorder. Individuals can overcome mental disorders by learning to use more appropriate cognitions. Individuals are in control of their thoughts Many of these thoughts have a ‘must’ quality about them. E.g. I ‘must’ perform well and win the approval of others. I ‘must’ lose weight and be thinner. People with eating disorders usually show a substantial difference between their estimation of their actual body size and their desired body size. Ellis (1962) ABC Model • A: Activating event (e.g. someone saying that fat people are ‘disgusting’) • B: Belief (if I’m not thin, people will think I’m ‘disgusting’) • C: Consequence (may fear food as they think it’ll make them put on weight) Limitations 1. Blames the patient Suggests patient is to blame so may ignore situational factors e.g. may ignore that a death in the family may have caused depression. Sometimes it is something in the environment that needs to change, rather than the persons thoughts. e.g. Emotional abuse from a husband/wife: changing a person’s thoughts isn’t going to stop the abuse from happening. 2. Consequence rather than cause Do faulty thoughts cause depression or does having depression alter your thought? 3. Irrational beliefs might be realistic Alloy and Abrahams (1979) ‘Sadder but wiser effect’ They found that depressed people gave more accurate estimates of the likelihood of disasters compared to non-depressed people.
  7. 7. SwindonAcademySixthForm 7 Psychological therapies for phobias, for example, behavioural, psychodynamic and cognitive-behavioural, including their evaluation in terms of appropriateness and effectiveness Systematic Desensitisation: hierarchy of fears. Relaxation techniques in between. Based on the idea that you can’t be anxious and relaxed at the same time. Hellstrom: participants showed an improvement after just 3 hours Marks: 80% success rate for treatment -Only really works on specific phobias -commitment -time Cognitive Behavioural Therapy (CBT) Based on the idea that anxiety arises from, and is maintained by irrational beliefs. The goal of the therapy is to challenge those beliefs. Davy: Developed coping strategies to downplay people’s fears Downward comparison: ‘Other people are having a worse time than me’. Denial: ‘This has not happened to me’ Cognitive disengagement: ‘This is not important enough to get in an anxious state about’ Faith in social support: ‘I have family and friends to support me’ Dysfunctional thought diary: Write down automatic negative thoughts Rate them, write a logical alternative, and then rerate. e.g. Automatic negative thought: If I see a spider I will die (belief: 60%) Rational response: If I see a spider I will experience an intense fear response. (belief: 80%) Rerated belief: If I see a spider I will die (belief: 10%) Cahill et al (2003) By the end of the therapy which lasted 12-20 sessions, 71 percent of patients who had completed their therapy experienced significant reduction in their symptoms. However, only 13% of the patients who did not complete the therapy showed improvement. Effectiveness and appropriateness - CBT only seems to be effective in treating social phobias. However it is less successful with specific phobias as sufferers are already fully aware that their phobia is irrational and excessive -could be due to the therapist. Kuyken and Tsivikos (2009) up to 15% of the effectiveness of CBT may be attributable to the competence of the therapist.