Mental Disorders >> Phobic Disorder

1. Psychology Super-Notes PsychoTech Services Psychology Learners Version 1.0 Anxiety Disorders Phobic Disorder M. S. Ahluwalia

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10. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders - Phobic Disorder >> Contents Contents 1. Introduction to Anxiety Disorders 2. Phobic Disorder - Diagnosis & Epidemiology 3. Types of Phobic Disorders 4. Case Study 5. Aetiology 6. Treatment 10

11. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Introduction to Anxiety Disorders 1. Introduction to Anxiety Disorders (1/2) 11 Anxiety is normal… • Anxiety is a common reaction to stress. It prevents humans from being careless. • Examples: • Anxiety about your examination makes you study. • Anxiety over her baby’s health makes a mother care for her baby. …however, in same situations anxiety can be abnormal • If anxiety crosses a reasonable limit, it might become a disorder • Examples: • when one is so anxious that he/she has a breakdown in the exam hall, forgetting everything • when a mother is so anxious about her baby’s health, that she spends day and night praying to God Nature of Anxiety Fear • Fear is a basic emotion of human beings associated with the perception of a real threatening situation and involves the ‘fight or flight’ response activated by the sympathetic nervous system. • Example: If a street thug attacks you, you would feel intense fear. Then, you would either run for dear life, or hit him back. • Thus fear involves: • cognition of the threatening object, • subjective cognition of being in danger, • physiological components like increased heart rate, • behavioural components like running or hitting. Anxiety • Anxiety also involves subjective perception of threat, physiological changes and some behavioural reaction. • However, there is no immediate threat - you are projecting the threatening situation in future and reacting to it as if it is imminent. If you cannot go out of your home because of apprehensions of an attack by a hoodlum, it is anxiety. • Anxiety serves an adaptive function - it prepares a person for fight or flight if the danger really comes. But if the person avoids the situation that in her perception may cause the danger, and if such imagined situations are unrealistic, then the effect becomes debilitating.

12. Psychology Super-Notes PsychoTech Services Psychology Learners PsychoTech Services Psychology Super-Notes Psychology Learners 12 One may distinguish between adaptive anxiety and pathological anxiety by assessing the realistic probability of the occurrence of the object of anxiety and by assessing how dysfunctional it makes the person.

13. Psychology Super-Notes PsychoTech Services Psychology Learners Focus of this document Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Introduction to Anxiety Disorders 1. Introduction to Anxiety Disorders (2/2) 13 Common Characteristics/Nature of Anxiety Disorders • Cognition or subjective perception of danger – may be accompanied by vivid, occasionally morbid, images of the difficulties encountered. • Physiological Responses - through activation of sympathetic nervous system. Usually includes dilated pupils, increased heart rate, trembling, breathing discomfort, nausea etc. • Behavioural Responses - usually a tendency to avoid the dreaded situation. Except in OCD and sometimes PTSD, where repetitive behaviour is observed. Anxiety Disorder Anxiety Disorder is a blanket term that covers a group of disorders characterized by irrational fear of some thing or situation. The person is usually aware of the irrationality. 1 Panic Disorder (with or without agoraphobia) 2 Phobic Disorders (specific or social) 3 Generalised Anxiety Disorder (GAD) 4 Obsessive Compulsive Disorder (OCD) 5 Post Traumatic Stress Disorder (PTSD) Types of Anxiety Disorders (DSM IV TR)

15. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Diagnosis and Epidemiology 2. Phobic Disorder Diagnosis and Epidemiology 15 Phobia Derived from the name of the Greek god ‘Phobos’ who used to frighten his enemies, a phobia is an intense and irrational fear of some object, living being or situation. Diagnosis To be diagnosed as suffering from phobic disorder (as per DSM IV–TR): • one must have a persistent and disproportionate fear of some specific object, social situation or crowded place that actually carries little danger. • Exposure to the phobic stimulus almost invariably produces intense anxiety response. • Patient knows that the fear is unreasonable, but has no control on the reaction. • The phobic situation is usually avoided, or if forced to endured, may be tolerated with great discomfort. When forced to encounter the phobic stimulus, the reactions may be like panic attack, or a little less severe. • The attention of the person facing the phobic object is directed completely toward it, the affect is intense fear and the behavioural reaction is escape. • As soon as the person escapes from the presence of the phobic stimulus, the negative affect and accompanying physiological reactions subside. • Thus, the flight reaction is reinforced as it provides relief from tension. Epidemiology of Phobic Disorder • Not all phobias are of equal prevalence. • Social phobias are more common than specific phobias. While specific phobias are estimated to be around 4.5%, the estimated prevalence of social phobia is around 11%. • Phobias, like panic disorders, are more common in women than men.

17. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Types of Phobia 3. Types of Phobia (as per DSM IV–TR) 17 1. Specific Phobia • Specific phobias are the irrational fear of specific objects, animals or situations. • Examples: fear of closed space (claustrophobia), fear of fire (pyrophobia) and even fear of phobias (phobophobia.) • Specific phobias can be divided into some subtypes: • animal type - cued by animals or insects • natural environment type - cued by objects in the environment, such as storms, heights, or water • blood-injection-injury type - cued by witnessing some invasive medical procedure • situational type - cued by a specific situation, such as public transportation, tunnels, bridges, elevators, flying, driving, or enclosed spaces • other type - cued stimuli not covered above, such as choking, vomiting, or contracting an illness. 2. Social Phobia • Social phobia is an irrational intense fear of being exposed to a crowd of people, specially where one has to perform and be evaluated. • Often extreme feelings of shyness and self-consciousness build into a powerful fear, making it difficult to participate in everyday social situations. • People with social phobia can usually interact easily with close and familiar persons, but meeting new people, talking in a group, or speaking in public can trigger the phobic reaction. • Often situations where one might be evaluated become the phobic situation. • Normal individuals occasionally have social anxieties, especially under a judgmental situation, but a person with social phobia often becomes incapable of normal social interaction. 3. Agoraphobia • Agoraphobia refers to the fear of public spaces where many people congregate. • Agoraphobia without history of panic disorder has been given a special emphasis in DSM IV–TR. • It develops slowly and insidiously from early adolescence or late childhood, and gradually becomes debilitating. • Panic or Phobia? • If it is a part of the panic attack, it should be coded within Panic disorders. • If it occurs as a source of anxiety and a strong urge to avoid, but does not constitute a palpable panic attack, it should be coded within Phobia.

19. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Case Study 4. Phobia Case Study – Specific Phobia • Background − Raju, 25, comes from a lower class family of fishermen. − They earn livelihood by fishing in shallow backwater or rivulets branching out from the bigger rivers. − He studied up to class 5 in the local school, but stopped due to poverty. • Situation − As a child, he accompanied his father to the backwaters, especially where they cultivated prawns. − Sometimes, very rarely, crocodiles would swim in from the river with which the backwater was connected. There were stories about crocodiles killing men around the village. Everybody had heard these, but since crocodiles come rarely, everybody works in knee deep water without much anxiety. • Problem − Starting in early adolescence, Raju gradually became afraid of crocodiles, which then turned into specific phobia - Herpetophobia. He was unable to work in the water, because if he sees any shadow, even those of underwater plants and fish, he got uncontrollably scared. − As Raju’s family has no land to cultivate, and Raju doesn’t have any other skill, he is unable to work. So he has become financially dependent on his poor family. − Raju understands that his fear is irrational, and he has never even heard of a man being attacked by a crocodile in their locality. − He understands that he is becoming a burden on his family; but he cannot overcome the intense fear. − While he attributes the fear to the stories he had listened to in childhood, he knows that these are not enough to provoke such strong reactions. 19

21. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Aetiology 5. Phobic Disorder Aetiology 21 Causes of Phobic Disorder 1 Biological Factors 1.1 Genetic Factors 1.2 Temperament 1.3 Evolutionary Factors 2 Psychological Factors 2.1 Psychoanalytical Approach 2.2 Behavioural Approach 2.3 Cognitive Approach

22. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Aetiology 5.1. Biological Factors Biological factors are of less importance in phobias than in panic disorders. 22 1. Genetic Factors • The genetic basis of phobias has been suggested by some studies, but it has not been well established. • At best the impact of genetic factors is modest. 2. Temperament • Temperament plays a significant role in developing phobia. • Some children are temperamentally jumpy or easily aroused. This lability- stability dimension is a function of the predisposition of the autonomic activity. • Those who are easily aroused may have greater chance of developing anxiety disorders in later life. 3. Evolutionary Factors • People are more likely to develop fear of snakes or heights than of books or cups. • Thus, there seems to be a ‘preparedness’ to consider some objects as more phobic than others. • This preparedness has been retained by nature because the primates who identified these danger signals quickly had a survival advantage. • However, for the normal person, the reality of the danger is judged, while for the phobic person the reaction is exaggerated.

23. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Aetiology 5.2.1. Psychoanalytical Approach • The psychoanalytical approach emphasises the role of unconscious needs and conflicts. • Freud, in his description of fear of horses in little Hans proposed that phobias are the ego’s way of dealing with childhood conflict. • For example, Hans could not resolve his oedipal conflict properly and his fear of father was displaced onto horses. • Other psychoanalytical models attribute phobias not to id drives, but to disastrous interpersonal experiences. The mistrust and generalised fear of environment seems to be displaced on the phobic object or situation. • Social phobia may be particularly well explained by this latter view. 23 Psychoanalytical Explanation of Phobia Repressing force of the ego Unconscious conflict seeking expression Displacement on the phobic object Defensive Solution Criticism of Psychoanalytical Approach Learning theorists state that many phobias develop as result of association with a fear eliciting object, and we don’t need to go deeper to the id impulses for explaining them.

24. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Aetiology 5.2.2. Behavioural Approach: 1. Conditioning • Watson and Rayner, through their experiments, conditioned little Albert to fear furry objects by associating a rat with a loud bang. • The learning theorists take this experiment on avoidance conditioning as the model of phobic reactions. • Phobia, as per this approach, is the end result of a process of a neutral stimulus being turned into a phobic object due to unwarranted association in time with a feared object. • Initially the association creates the fear of the neutral stimulus, and then escape or avoidance of the stimulus results in relaxation. • This relaxation in turn acts as a reinforcer and maintains the phobia. 24 Explanation of Phobia by Conditioning An object elicits real fear (Unconditioned Stimulus) Fear response is attached to a neutral object The neutral object, over time, begins eliciting fear (Conditioned Stimulus) Escape or avoidance of conditioned object causes relaxation Relaxation reinforces/ maintains the phobia

25. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Aetiology 5.2.2. Behavioural Approach: 2. Modeling • Vicarious learning refers to the fact that a child models behaviours, but also attitudes and emotions. • The modeling theory proposes that phobias are learnt via observational learning processes. • Example: If a child repeatedly sees her mother being afraid of something, the same would be observed in the child also. 25 Explanation of Phobia by Modeling Criticism of Learning Approach • While learning theory justifies the origin of a number of phobias in some cases, it is unable to explain all phobias. • It is unable to explain phenomenon where there is a role of preparedness (biological factor). • Thus, learning may play a role in phobia, but it cannot be the whole story. Role model expresses fear of a being or thing Child observes repeatedly Child develops fear of the being or thing

26. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Aetiology 5.2.3. Cognitive Approach • Cognitive approach to phobias indicates a greater selective attention towards the phobic object. • There is often an underlying core belief that negative things are going to happen. − Particularly in case of social phobia, but also in other specific phobias, catastrophic outcomes are believed to be inevitable, thus distorting the reality for the person. • The core belief may remain at a non-conscious level, thus making it difficult to modify. − However, if the person is taught to look into her own erroneous assumptions and cognitive biases, the distortion in thought process may be identified. 26 Cognitive Explanation of Phobia Core belief about inevitable negative events Automatic thoughts about impending catastrophe Phobic Reaction Core belief justified

28. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Treatment 6. Phobic Disorder Treatment 28 Treatment of Phobic Disorder 1 Pharmocology 2 Psychological Approaches 2.1 Psychoanalytical Approach 2.2 Behavioural Approach 2.3 Cognitive Approach As in case of panic disorder, anxiolytics and anti- depressants are used for treating phobic disorders, particularly social phobia. They have greater effectiveness They try to unearth repressed conflicts and deal with them at a mature level than by displacing them onto objects and situations • Cognitive approach is not the best option for specific phobic disorders as the person already knows the unreasonableness of her fear. Simply making her see the irrationality is of little help. • Exposure to the situation seems to be essential for reduction of specific phobia. • However, cognitive behaviour therapy is useful in case of social phobia. There are often automatic thoughts about self and others underlying social phobia. Exploring such erroneous automatic thought and making the client approach it from a new perspective have been helpful in treating social phobia. In real life the therapist might go for a combination of therapies depending upon the specific need of the client. Methods like flooding, modeling, systemic desensitization, and relaxation techniques can be used. Details on next page >> <<

29. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Treatment 6.2.2. Behavioural Approaches (1/2) 29 Systematic Desensitization Process Step 1 • Before starting systematic desensitisation, teach your client the relaxation technique scientifically. Step 2 • Prepare the ‘hierarchies of anxiety’, and design situations to expose her gradually from the lowest level of anxiety to the highest. Step 3 • Start with the lowest level • Example: if client is afraid of snakes, show her a cartoon picture of a snake, which would probably not elicit phobic responses in her. • Ask her to relax in the presence of this picture, and she should be able to do it well. Step 4 • Show her a perfectly realistic photograph of a snake • She may be able to relax even though she is a bit uncomfortable • .You continue till she becomes comfortable with this step. Step 5… • Then show her a 3D picture • She may become disturbed. • You continue working with her till she learns to relax in front of it. • Then you show her a video – and so on. Final Step • Finally, when she is ready to take her chance, take her to a snake park to show her live snakes • Ask her to relax and enjoy. • You continue till she becomes comfortable. 1. Systematic Desensitization A therapeutic technique based on behavioural approach where the client is exposed to the phobic object or its image in graded stages, starting from a point where she is fully relaxed, and then guided progressively toward staying relaxed even in situations where she experienced intense fear

30. Psychology Super-Notes PsychoTech Services Psychology Learners Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Treatment 6.2.2. Behavioural Approaches (2/2) 30 • It is the opposite of graded exposure – as you expose your client straightaway to the feared situation or object and ask her to relax. • Example: This is the technique rural people take for teaching swimming to young boys. They throw the protesting child in water with a cloth tightly wound around his waist. The child struggles and gasps in water, and at last through random movements float up. He may be rescued at any moment with the help of the cloth tied around his body. The same may be used with phobic people. • Flooding needs to be used cautiously as there is a risk that the client may be traumatized. 2. Flooding (Exposure Therapy) • A therapeutic technique based on behavioural approach where the client is exposed all at once to the phobic object. • She is instructed to relax instead of being afraid. • Once she can relax in presence of the phobic object she is able to master her fear. 4. Modeling • A therapeutic technique based on behavioural approach where the client observes others in the group facing the same situation. • Seeing others in a group facing the situation without fear may help the client in trying to do the same. 3. Relaxation Techniques • A behavioural technique that includes any method, process, procedure, or activity that helps a person to relax and to be free from stress and anxiety. • Example: progressive muscular relaxation, controlled breathing, meditation , biofeedback etc.

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