5.+BPSF+Phobias

=Unit 4.=

Dot Point 5.
**• Application of a biopsychosocial framework to understanding and managing simple phobia as an example of an anxiety disorder:** ** Anxiety ** : a state of physiological arousal associated with feelings of apprehension, worry or uneasiness that something is wrong or that something unpleasant is about to happen. ** Anxiety Disorder: **Anxiety disorder is a group of disorders characterised by chronic feelings of anxiety, distress, nervousness and apprehension or fear about the future, with a negative effect. Anxiety disorders are distinguished from ‘normal’, everyday anxiety in that anxiety disorders involve anxiety that: • is more severe (intense), • lasts longer (anxiety may persist for months instead of going away after the anxiety-provoking situation has passed), and • significantly interferes with a person’s daily life and stops them doing what they want to do. ** Phobia: **A phobia is an excessive or unreasonable fear directed towards a particular object, situation or event that causes significant distress or interferes with everyday functioning. Key characteristics are: • anxiety: exposure to the phobic stimulus almost invariably induces an immediate anxiety response; • awareness: the person recognises that their fear is excessive or unreasonable; • avoidance: the phobic situation is avoided or else is endured with intense anxiety or distress. As with all other disorders in the DSM-IV-TR, the person’s anxiety and avoidance behaviour significantly interfere with their everyday life and causes them great distress. According to the DSM, a person’s fear of a specific object or situation must have persisted for //at least six months// for them to be diagnosed as having specific phobia. There are two forms of Phobias: Simple (specific) phobia and Complex phobia. • **Simple (specific) phobias** involve an intense fear that is restricted, or confined, to a single ‘specific’ stimulus such as fear of heights, ladders, frogs, enclosed places, etc. • **Complex phobias** involve a non-specific, more ‘general’ fear that usually involves a ‘number of anxieties’ so it is more ‘complex’, e.g. in fear of flying, the person may be afraid of crashing, being enclosed in the plane, //and// losing self-control; with agoraphobia, the person may be afraid of entering shops, crowds and public places, travelling in trains, buses and planes //and// is also anxious about being unable to escape to a place of safety. ** – Biological Contributing Factors to a Fear-Anxiety Response : ** ** Amygdala ** : a region in the brain which is involved in processing emotions – in this context – fear. ** Noradrenaline ** : mediates the physiological symptoms of fear / anxiety through the sympathetic nervous system. ** The HPA Axis ** and **Adrenaline** are involved with the stress response. ** Role of the stress response: ** ** Role of the neurotransmitter gamma-amino butyric acid (GABA) in the management of phobic anxiety ** • **GABA (gamma-amino butyric acid)** is the major inhibitory neurotransmitter that makes presynaptic neurons //less likely// to fire in the brain. • GABA inhibitory action counterbalances the excitatory action of glutamate (that makes presynaptic neurons //more likely// to fire). • It is found in the CNS (brain and spinal cord).
 * ** DSM-IV-TR Specific Phobia Categories ** || ** ICD-10 Phobia Categories ** ||
 * Animals ||  Specific  ||
 * Situations ||  Agoraphobia  ||
 * Blood / injections ||  Social  ||
 * Natural environments ||   ||
 * Other (choking, dying, illness, falling etc) ||   ||
 * HPA Axis activity results in the release of **cortisol** from the **Adrenal Gland** above each kidney.
 * Adrenaline hormone results in the wide range of physical changes discussed earlier.
 * A phobic reaction is an exaggerated fear response.
 * From a physiological perspective, an extreme fight –flight response occurs when the individual encounters the phobic stimulus or anticipates such an encounter. The terror experienced is marked by physical anxiety symptoms, cognitive symptoms of fear of the object or situation (fright/fight response), and an intense desire to escape (flight response).

phobic anxiety involving a highly aroused state (e.g. when a person with a specific phobia encounters their phobic stimulus, their sympathetic nervous system and HPA axis are activated resulting in a highly aroused physiological state); • Benzodiazepines being GABA agonists (i.e. they mimic GABA’s inhibitory effects) and therefore reducing physiological arousal and promote relaxation; • Benzodiazepines may therefore be successfully used to manage or treat phobic anxiety (e.g. someone with a fear of flying may take a benzodiazepine tablet before getting on a plane).
 * Benzodiazepines**: Drugs that are GABA agonists and may be used to manage or treat phobic anxiety.
 * Valium is the best known example – it increases the strength of GABA Binding allowing the GABA to act for longer and more strongly in dampening the activity of the amygdala and HPA – thereby reducing anxiety and fear.

**– Psychological Contributing Factors:** **Psychodynamic Model** The psychodynamic model has two key assumptions that underpin its explanation of the development of specific phobia and other mental disorders Key assumptions are: all mental disorders are caused by unresolved psychological conflicts of which we are not consciously aware, but which still have a considerable influence over our conscious thoughts and behaviours; unconscious psychological conflicts stem from early childhood experiences (e.g. infancy and early childhood such as the Oedipus complex), during which out instinctive impulses (‘urges’) and society’s view of what is ‘acceptable’ behaviour often clash. The Oedipal complex is central to explaining phobic reactions in the psychodynamic model The oedipal complex: a developmental conflict that emerges during Freud’s phallic (third) stage of psychosexual development (4–5 years);

it involves the unconscious, powerful, passionate love and desire that the male child develops toward his mother, and, fear that his father will become aware of this love and desire and punish him with castration.

Freud’s psychodynamic model proposes that:

the development of a specific phobia is due to an unresolved Oedipus complex that arises during the phallic stage of a child’s development;

a specific phobia develops when the Oedipus complex is not successfully resolved by the use of the defence mechanism called repression and another defence mechanism called displacement is used instead;

when displacement is used, the anxiety caused by the unresolved Oedipus complex is displaced or ‘redirected’ away from the true source of the fear (the father) and onto a seemingly unimportant, irrelevant object or situation which then becomes the phobic stimulus; the male child can then deal with their unresolved conflict and the anxiety associated with it by avoiding the phobic stimulus. Freud explained this through the case study of Little Hans (1908).

Freud proposed that: Little Hans developed a specific phobia of horses because he was struggling to resolve his Oedipus complex;

the anxiety and fear felt by Little Hans could not be expressed toward the real object of fear: his father;

so, Little Hans used displacement and consequently ‘displaced’ his fear of his father onto horses, which symbolised or reminded him of his father and became the phobic stimulus;

Freud believed that Little Hans’ fear of being bitten by a horse actually symbolised his fear of castration by his father.

**Behavioural Model** Key assumptions of the behavioural model in explaining the development of specific phobia and other mental disorders

Key assumptions are:
 * Phobias are //learned// through experience and may be acquired, maintained or modified by environmental consequences such as rewards and punishment
 * Classical conditioning processes play a role in the acquisition (or ‘development’) of a specific phobia and operant conditioning processes play a role in the persistence (or ‘maintenance’) of specific phobia;
 * ‘Abnormal’ or ‘dysfunctional’ ways of thinking, feeling and behaving are therefore //learned// through classical and operant conditioning processes (and can therefore also be modified).

How a specific phobia may be acquired through classical conditioning processes

•Specific phobias are acquired through classical conditioning processes when an experience(s) in which the now feared (phobic) stimulus has been paired with some previously unconditioned (aversive or traumatic) fearful stimulus.

That is, a pairing of a previously neutral stimulus and an aversive UCS results in a conditioned fear response (CR) to the CS.

**Acquisition and maintenance of phobias through operant conditioning:** __Acquisition:__ Generally, a specific phobia is acquired and maintained through operant conditioning processes when the individual repeats a behaviour (operant) that has desirable consequences or will enable it to avoid undesirable consequences.

Phobias can be acquired by operant conditioning processes through //positive reinforcement.// __ Maintenance: __ Phobias can be maintained by operant conditioning processes through //negative reinforcement.// When a person is confronted with their feared object or situation, the person experiences intense, almost unbearable, anxiety but their fear/anxiety is //reduced// by avoiding the object or situation. The avoidance behaviour is therefore negatively reinforced (more likely to occur again in the future) and the phobia is maintained. Application: LITTLE ALBERT OPERANT CONDITIONING: Little Albert’s specific phobia of white rats (and all things white and furry) was then maintained through operant conditioning, specifically, through negative reinforcement.


 * Cognitive Model (to explain Phobias) **


 * Maladaptive (Negative) Cognition ** : A cognitive theory of phobia, that says that a person may experience shame or embarrassment at the thought that he or she may become frightened in public and may avoid such a risk (further negatively reinforcing the avoidance behaviour).


 * Key Assumptions: **

The focus or emphasis of cognitive models in explaining the development and persistence of a specific phobia: __Focus__: how the individual processes information and thinks about the phobic stimulus and related events (e.g. their perceptions, memories, beliefs, attitudes, appraisals and expectations). __Emphasis:__ how and why people with a specific phobia have an unreasonable and excessive fear of a particular phobic stimulus. Cognitive biases: Cognitive biases are tendencies to think in some kind of erroneous/mistaken or distorted way that involves an error(s) of judgment and faulty decision-making (and therefore also referred to as ‘mistakes in thinking’ or //cognitive distortion//s).

Note: In relation to phobias, cognitive biases make individuals more prone or vulnerable to experiencing fear and anxiety in response to a phobic stimulus.

Types of Cognitive Bias associated with Specific Phobias: e.g. a person with a phobia of dogs may notice, upon arriving at a BBQ at a friend’s house, that there is a dog’s lead hanging on a coat hook in the hallway of the house—they are likely to be the first or only person to have noticed this e.g. a person with a dental phobia remembers the one and only time they had a frightening and painful dental experience but forgets all of the other times their dental experiences were not frightening or painful e.g. a person with a phobia of flying may interpret turbulence as a sign that the plane’s engine has failed so the plane is going to nose-dive and crash; e.g. a person with a phobia of bees may think that any bee they encounter will attack and kill them.
 * Attentional bias ** : the tendency to selectively attend to threat-related stimuli rather than to neutral stimuli,
 * Memory bias: ** when recall or recognition is better for negative or threatening information than for positive or neutral information
 * Interpretive bias: ** the tendency to interpret or judge ambiguous stimuli and situations in a threatening manner
 * Catastrophic thinking: ** the tendency to perceive objects or events as being far more threatening, dangerous or insufferable than they really are and will result in the worst possible outcome

**The Use of Psychotherapies in Treatment:** ** Cognitive Behavioural Therapy (CBT) ** ** Systematic Desensitisation ** ** Flooding ** **– Socio-cultural contributing factors: specific environmental triggers such as being bitten by a dog; parental modelling and transmission of threat information** ** Specific Environmental Triggers: ** where something in the environment triggers the anxiety-fear response. All Specific Phobias have a direct relationship to the person’s environment or their knowledge of it. ** Parental Modelling ** : where parental influences have shaped the development of anxiety disorders of their children, particularly relevant in **social anxiety**. ** Transmission of Threat Information: ** Where parental modelling has transmitted strong threat information from specific stimuli to their children. Often occurs for stimuli a parent has a phobic response with themselves. - Also occurs through other ‘gatekeepers’ including peers, friends, teachers and the media. – **The interaction between biological, psychological and socio-cultural factors which contribute to an understanding of the disorder and its management** ** Add Resources: **
 * CBT helps people with phobias face up to their fears by teaching them new skills to help them react differently to the situations that trigger their phobia.
 * Patients also learn to understand how their thinking patterns contribute to the:
 * Situations that trigger their phobia
 * Symptoms
 * How to **Change** their beliefs to reduce or stop these symptoms and, in time, accept whatever was causing their extreme anxiety.
 * A process where individuals extinguish the association between the phobic stimulus and anxiety through a series of graded steps – known as a fear hierarchy.
 * Incremental exposure allows the patient to gradually face the phobic stimulus and replace the fear response with the specific relaxed response.
 * Flooding involves exposing a phobic person repeatedly to the object of fear either in vivo (real life/natural setting) or indirectly by imagination or virtual reality. – The technique initially creates significant distress in the patient.
 * It is not suggested for most individuals because it can trigger a higher level of sensitisation or fear reinforcement.
 * It works well when the individual is highly motivated and given appropriate support through the process.
 * Eventually through sustained contact the patient learns to relax in the presence of the phobic stimulus.