1. Anxiety Disorder: Phobia
Aaaaaaahhhhhhhhhh peaches!

2. Anxiety
Anxiety is a normal response to an anticipated threat in the environment. It serves a vital function in preparing the individual to respond to the threat and is the precursor to the fight-or-flight response. That is, anxiety is a preparatory response to a real threat.
Example: We feel anxious when we walk down a dark street in an unfamiliar neighbourhood. This is then replaced with a fear response when an armed mugger confronts us.

3. Anxiety
Anxiety consists of three sets of responses – physiological, cognitive and psychological – that occur simultaneously and are seen as one general response. The general anxiety response merges with the stress response as the threat, or the perception of the threat, materialises.
Physiological: Increased heart rate, sweating, flushing/blushing/feeling faint, increased breathing/feeling short of breath, lump in the throat/choking sensation, dry mouth, butterflies in stomach, nausea, diarrhoea, need to urinate, pins and needles, dizziness, tremor/shaking

4. Anxiety
Cognitive: Fear of impending doom, death, embarrassment, losing control, being trapped
Psychological: Feeling tense/restless, sense of unreality, time moving slowly, hypervigilant, difficulty concentrating

5. Anxiety as a disorder
Although anxiety is a normal and expected response it can occur in people in unwanted or unexpected times or with a severity far in excess of the threat. When this happens it can be a marker of an anxiety disorder.
The ICD-10 and DSM-IV-TR list a number of anxiety disorders where the anxiety response is too great, inappropriate or overly persistent, causing distress and impairment to the person with the disorder.
Examples of anxiety disorders are:
Post traumatic stress disorder (PTSD)
Agoraphobia
Obsessive-compulsive disorder
Social phobia
They are relatively common throughout the world.
After 3 – what examples can students think of?

6. Anxiety as a disorder
Video: OCD
Girl with OCD

7. Types of Phobias
There are three characters of phobia indentified in ICD-10:
Specific
Agoraphobia
Social

8. Specific Phobia
A phobia is an intense, irrational, persistent fear of a stimulus that is out of proportion to the actual threat and may impact a person’s functionality.
Common examples of stimuli for phobia are:
Animals such as spiders, snakes, dogs, sharks
Injections/blood
The natural environment such as heights, the dark, storms
Common situations such as being in a lift
Flying in an aeroplane
Medical or dental procedures
After 2 – ask students for examples

9. DSM phobia categories Animals Situations Blood / injections
Natural environments
Other (choking, dying, illness, falling etc)

10. Specific Phobia
Ophidiophobia

11. How many phobias? Traditional phobia names use a Greek prefix
Most specific phobias are not listed in the DSM as there are literally too many to list
Simply classified as ‘specific phobias’
ICD -10 uses the term ‘specific’ interchangeably with ‘isolated’
Some phobias are less specific eg. Agoraphobia
These are referred to as ‘complex phobias’

12. Anglophobia- Fear of England or English culture

13. Specific Phobia
While many of these evoke anxiety in people to an extent, for it to be a phobia, a person must:
Experience or anticipate the experience of the object or situation as extremely anxiety-provoking if not terrifying
Must seek to avoid or minimise exposure to the object or situation
Be impaired in their social and occupational functioning as a consequence
The person may adapt their lifestyle to take into account their phobia. For example, they may never fly, or may never go into an area where they might see a snake. But for many people with phobias, encountering their phobia may be unavoidable as in the case of spiders, blood/injections or heights.

14. Specific Phobia
Ablutophobia
Ablutophobia

15. Specific Phobia Needle Phobia
Specific phobias are common with up to one in eight people reporting a specific phobia over their lifetime.
Women are more than twice as likely to be affected as men regarding most phobias except blood/injection phobias, which are approximately equal.
Specific phobias also tend to start early, with animal and blood/injection phobias beginning early in childhood, and situational phobias usually by the early twenties.
Needle Phobia

16. Phobias

17. Tyrannophobia- Fear of tyrants

18. Application of the biopschyosocial framework to phobias
Looking at -
Biological Factors
Psychological Factors and
Social/Environmental Factors
that may influence onset of phobias and that may be used to help overcome phobic reactions.
About Specific Phobias
In looking at the biopsychosocial approach, we are looking at the biological, the psychological and social factors that may have an impact on why a person has a phobia and also how each of these might be used to help manage or overcome the phobia.

19. Biological factors that may influence susceptibility to phobias
Genetic inheritance
Neurotransmitter imbalance

20. Biological factors that may influence susceptibility to phobias
Genetic Factors
It seems that specific phobias are more common in close relatives of people with a specific phobia and most likely if your twin has a phobia. This suggests that genetic factors contribute to the transmission of the disorder, however, even if your twin has a specific phobia, there is an 80% chance that you won’t develop it, indicating that environmental and non-genetic factors are much more important.
In looking at the biopsychosocial approach, we are looking at the biological, the psychological and social factors that may have an impact on why a person has a phobia and also how each of these might be used to help manage or overcome the phobia.

21. The role of Gamma-amino-butyric acid…….GABA
Not enough Yo gaba gaba makes me anxious!

22. GABA
Gamma-amino butyric acid is the primary inhibitory neurotransmitter in the CNS.
Inhibits postsynaptic neurons – stops them passing on the neural impulse
Gets in the synapse to block transmission
Helps fine tune brain activity, keeps neural transmission from getting out of control
Without GABA neural activation could spread like fire throughout the brain causing seizures

23. glutamate 2nd most common neurotransmitter in the brain
Excitatory neurotransmitter
Makes postsynaptic neurons more likely to pass on the neural impulse
Gets the post synaptic neuron excited so it requires less stimulation to make it fire
Also plays a role in learning and memory, strengthening synaptic connections

24. GABA
Stop the message!
GLUTAMATE
Get the message going!

25. GABA and anxiety
Lack of the neurotransmitter GABA might lead to over stimulation, and thus heightened anxiety
Benzodiazepines – a class of drugs that ‘calm down’ neural activity. Valiam, Xzanax, Rohypnol, Serepax etc.
All drugs are either Agonists – mimic the activity of a neurotransmitter
Or Antagonists – inhibit the activity of a neurotransmitter

26. Benzodiazepines - agonists to control phobic reactions
Mimic the activity of GABA in inhibiting post synaptic neural activity
Effective in the management of anxiety disorders
So anxiety disorders might be the result of a dysfunctional GABA system, not making enough neurotransmitter
One study showed that anxiety disorder sufferers have 22% less GABA than healthy individuals
Conversely studies show that antagonists can increase anxiety

27. GABA supplements?
GABA like substances found in many foods, supplements also available from health food retailers
Unlike drugs that are specifically manufactured for the purpose, there is no evidence that supplements can penetrate the blood brain barrier
The blood brain barrier is a kind of filtration system that only allows certain substances into the brain

28. Psychological factors that may impact susceptibility to phobias
There are a number of psychological theories concerned with why people form phobias. These include:
Freud’s Psychodynamic Theory
Behaviouralist Theories
Cognitive Theories

29. Psychological factors – freud’s psychodynamic model
Mental disorders are caused by unresolved conflicts that occur in the subconscious
‘Skeletons in the closet’
Memories that are too distressing are pushed out of conscious awareness
As we grow up we progress through different psychosexual stages
Oral 0 – 2
Anal 2 -3
Phalic 4 -5
Latency 6 – Puberty

30. freud’s psychodynamic model
As we progress through these stages different parts of the body become the focus of attention and pleasure
Each stage has a critical developmental conflict that must be resolved to move onto the next stage
Unresolved conflicts cause anxiety
Freud’s anxiety refers to unpleasant feelings when our instincts make us do something that we will be punished for

31. freud’s psychodynamic model
We use defence mechanisms to protect ourselves from this anxiety
The ego (conscious part of the mind) distorts, denies or falsifies reality unconsciously
We can then ‘believe’ that there is no reason to be anxious
We lie to ourselves to be happy

32. freud’s psychodynamic model – oedipal complex and electra complex
Child develops sexual attraction to his opposite-sex parent
Below conscious awareness
Boys then fear their father who is bigger and stronger, believes punishment will involve castration
Tries to use Repression as a defence mechanism
Child identifies with father – being like dad will mean dad will be less inclined to punish me
If this doesn’t work, Displacement can be used
Anxiety directed onto another irrelevant object, then the child can avoid this stimulus and thus solve the initial conflict but now we have a fear of the displacement object.

34. freud’s psychodynamic model – pseudo science?
Based on very small (unhealthy) samples
Very subjective
Can easily shift the facts to fit the theory
Some useful ideas
Not used in its original form today by the majority of practicing psychologists but many psychologists still use the concept of an ‘underlying problem’ when trying to explain mental health problems.
Oedipal Complex

35. Psychodynamic model Video: The Oedipus Complex 1 min 53
Read pages 643 – 645 and complete activity 13.3

36. Papaphobia- Fear of the Pope

37. Psychological Factors: Behavioural Model
Behavioural theories (also known as conditioning or learning theories) of specific phobia suggest that phobias are acquired through experience, an initial negative experience of an object or situation (neutral stimulus) is learnt or associated with anxiety and fear. This learning may then be negatively reinforced by the person’s avoidance of the stimulus as this behaviour ‘takes away the feelings of anxiety’.
Behavioural theorists are therefore suggesting that classical conditioning plays a role in the ‘acquisition’ of the phobia, and operant conditioning plays a role in the maintenance of the phobic behaviour.
Next theory – behavioural model

38. Psychological Factors: Behavioural model
Phobias are learned
Learned through classical conditioning or observational learning (and possibly through operant conditioning)
Maintained through operant conditioning

39. Behavioural model – Watson and little albert

40. Behavioural Model
How might cynophobia, fear of dogs, be acquired through classical conditioning and then maintained through operant conditioning?
Students to draw flowcharts in their books before showing next two slides

41. Behavioural Model
Acquisition of a Cynophobia through Classical Conditioning
Neutral stimulus – Dog
Unconditioned stimulus – Being bitten by dog/Dog barking at a toddler
Unconditioned response – Fear of the dog
Conditioned Stimulus – Dog
Conditioned Response – Fear of dog
Generalised Conditioned Stimulus – All Dogs
Generalised Conditioned Response – Fear of all Dogs

42. Behavioural Model
Maintenance of Cynophobia through Operant Conditioning
Antecedent – Dogs, situation where a dog could be present
Behaviour – Avoidance of dogs at all costs
Consequence – Reduction/removal of anxiety
Type of Learning – Behaviour maintained through negative reinforcement

43. Behavioural Model
Behaviour theorists also suggest it is possible to acquire a phobia through operant conditioning. This could occur if the fear response exhibited to an antecedent stimulus is followed by a positive reinforcer.
How might cynophobia be acquired through operant conditioning?
Students to draw flow chart before showing next slide

44. Behavioural Model
Acquisition of Cynophobia through Operant Conditioning
Antecedent – Child sees a fierce dog
Behaviour – Child screams and shows a fear reaction
Consequence – Mother cuddles child
Type of Learning – Behaviour increased through positive reinforcement – next time child sees a dog they scream because they want attention from the mother but this now strengthens the fear response pathway.

45. Psychological Factors: Cognitive model
Focus is on thinking
How do people process information?
How do they think about the phobic stimulus?
Key assumption – people with phobias have a cognitive bias – a tendency to think in a way that involves errors and bad judgement and decision making

46. Cognitive model – attentional bias
Seek out and notice threatening stimuli over normal stimuli
Eg. Arachnophobias might notice a spider web in the corner while everyone else is looking at the painting on the wall
Tend to be hyper vigilant – always looking out for the phobic stimulus

47. Cognitive model – memory bias
Remember the bad things more readily
Eg. Only remember being dumped by a big wave, not the hundreds of small waves that were enjoyable to jump over
Memories reconstructed to be worse than the actual event

48. Cognitive model – interpretive bias
Neutral situations or stimuli interpreted as threatening
Eg. Fluff on the carpet is a spider, a dog running over happily is going to attack

49. Cognitive model – catastrophic thinking
Negative thinking in which things are percieved in the ‘worst possible’ light
What can go wrong will go wrong, and in a big way
Often underestimate their ability to cope with the situation

50. Socio-cultural factors that may impact susceptibility to phobias
There are a number of socio-cultural factors that may impact a person’s development of a specific phobia. These include:
Specific Environmental Triggers
Parental Modelling
Transmission of Threat Information

51. Socio-cultural factors –specific environmental triggers
Traumatic event involving the phobic stimulus
Fear learned through classical conditioning
Fear persists through operant conditioning
Research shows that the more severe the trauma the more likely it is that a phobia will develop
If the trauma is severe enough only one experience is necessary (unlike normal CC where repeated pairings are needed)
Not a complete explanation, some people do not develop phobias despite severe trauma

52. Socio-cultural factors – parental modelling
Child who observes an extreme fear reaction from a parent may imitate the same reaction
Modelling bravery can help children cope with fears

53. Socio-cultural factors – transmission of threat information
Delivery of information from others about potential threat
Children might develop a phobia if constantly warned about the dangers of going outside alone
Research suggests that fears develop largely due to negative information about a specific event, object or situation being communicated often enough

54. Socio-cultural factors
Transmission of threat from parents, peers, teachers or the media about potential threats may lead to acute fear of the stimulus. For example, some movies such as ‘Jaws’ and ‘Anaconda’ led to people developing fears of sharks and snakes.
Pages 652 – 653 of Grivas for assistance

55. Lutraphobia- Fear of otters

56. Psychotherapeutic treatment of phobias
Psychoanalytic psychotherapy aims to uncover the unconscious ‘real object’ of anxiety that has been displaced onto the stated phobic object or situation. As this displacement from ‘real object’ to phobic object occurred early in childhood it is thought that as the person becomes older and more mature this realisation will be relatively less confronting and therefore resolved.
The realisation takes place in therapy sessions and could possibly involve hypnosis.

57. Psychotherapeutic treatment of phobias

58. Psychotherapeutic treatment of phobias

59. Behavioural approach to treating phobias
Behavioural or conditioning theories propose a combined approach to the treatment of specific phobias.
The first is teaching the person relaxation strategies that allow them to control their anxiety response, such as control breathing and heart rate.
Once the person has mastered this they are subjected to an exposure therapy that may be graded – systematic desensitisation, or total – flooding.

60. Behavioural approach to treating phobias
Systematic desensitisation is an exposure therapy that uses a graded approach. After learning a relaxation technique, the phobic person is first exposed to a mild or trivial example of the feared stimulus, and allowed to relax in its presence. As they become less fearful, the intensity of the stimulus is gradually increased.
At each stage the person is allowed to acclimatise to the stimulus using the relaxation strategies before exposure to the next stage.
Although this may be a prolonged therapy, in the case of severe phobias, it is very effective.

61. Behavioural approach to treating phobias

62. CBT – behavioural component
Systematic desensitisation
Fear hierarchy
Attempts to replace fear response with relaxation
Patient taught relaxation techniques
Gradually introduced to fear inducing stimulus while practicing relaxation.

63. Behavioural approach to treating phobias
How would we treat our cynophobic person using systematic densensitisation?

64. Behavioural approach to treating phobias
Flooding is similar to systematic desensitisation except that the final stage or the worst case scenario is the only one used. In flooding the worst possible situation is physically and continually presented. The situation is repeated until the person overcomes their fear and is able to tolerate the exposure.
Although flooding is a quick form of therapy, it may be extremely distressing (which leads to ethical problems) and does not appear to provide better results than systematic desensitisation.

65. CBT – behavioural component
Flooding
Expose the patient to their fear straight away
They will panic at first
Soon realise that nothing bad has happened!

66. Behavioural approach to treating phobias
Overcoming a fear of balloons

67. Behavioural approach to treating phobias
How would we treat our cynophobic person using flooding?
Video – Girl Afraid of Pickles

68. Cognitive approach to treating phobias
A cognitive approach is often added to behavioural therapy, cognitive behavioural therapy or CBT.
This type of therapy aims to cognitively reconstruct the person’s thoughts and beliefs about the feared stimulus.
It does this by identifying and correcting negative and irrational thoughts and maladaptive beliefs. By providing alternative adaptive or corrective thoughts when the person is undergoing exposure therapy, it aims to facilitate the decrease in fear.

69. Cognitive approach to treating phobias
Three kinds of thoughts are targeted:
The irrational or unfounded fear of the object
The fear of fear, which prompts avoidance behaviour
The fear of being embarrassed in front of others

70. Cognitive behavioural therapy
CBT is focused in the present
Recognition that past events shaped now
However the focus of CBT is changing the current trend in thinking and behaving
Client taught to identify unhelpful thoughts and to shift thinking to more balanced helpful thoughts
Makes the client responsible for their thoughts rather than being a victim of them

71. CBT and phobias
Tries to develop a new understanding of the phobic stimulus
Identify anxiety related thoughts and cognitive biases
Look at evidence that supports/rejects these biases
Switch from unhelpful irrational thoughts to evidence based rational thoughts

72. Cognitive approach to treating phobias
How would we treat our cynophobic person using cognitive behaviour therapy?
Videos

73. Socio-cultural support in the treatment of phobias
Like other mental health problems, an important factor in ensuring successful treatment is to have a good support network.
Good friends!
Parents and peers need to be supportive – showing an understanding of the condition and helping during therapy. It is especially important to not ridicule the individual as this may decrease the likelihood of the individual facing the phobic situation for fear of embarrassing themselves.
Parents and teachers need to ensure that the bias presented in the media is not seen to be the only information available.
Video – friends scaring a mate with a spider

74. Some Strange Phobias
Weird Phobias 1
Weird Phobias 2
Weird Phobias 3