Anxiety Disorders Flashcards
1
Q
Definition of anxiety disorders
A
Anxiety refers to fear that is disproportionate to a given situation.
Different conditions may be triggered by particular stimuli, but all produce excessively fearful reactions in the individuals.
2
Q
Characteristics of anxiety disorders
A
- Characterised by a pattern of frequent, persistent worry and apprehension about a perceived threat in the environment
> key: actual threat posed is minor or non-existent, yet the individual perceives it as highly threatening - Common symptoms of anxiety
> muscle tension
> restlessness
> feeling constantly ‘on edge’
> difficulty concentrating due to being preoccupied with their worry
> tiredness and irritation due to sleep disturbance (have difficulty falling asleep or staying asleep) - Individuals may or may not realise that their anxiety is disproportionate, but they will almost certainly find it difficult to manage and control their worry.
- Panic attacks
> a common feature of some anxiety disorders and can last minutes or even hours
> can be very frightening experiences for the individual as well as those around them
> symptoms
» fear of dying or losing control
» sensation of shortness of breath or chocking
» nausea
» feeling dizzy or light-headed
» sweating
» accelerated heart rate - Anxiety may be generalised or very specific
> generalised occur in response to many different stimuli, such as in the case of Generalised Anxiety Disorder
> very specific as when experienced in relation to a unique stimulus
> consider some of these as phobias
» phobia is an extreme and irrational fear towards a stimulus and is disproportionate to the actual danger
3
Q
Types of anxiety disorders
A
- Generalised Anxiety Disorder (GAD)
> a long term condition wherein feelings of anxiety may be generalised over multiple situations and things (money, health, family, work etc), rather than a specific stimulus (phobia) - Specific phobia
> an intense and irrational fear of particular items
> individuals seek to avoid interference with them
> for a person to be diagnosed with a specific phobia, fear must occur right away when encountering the trigger - Social phobia/Social Anxiety Disorder
> an intense fear of being judged or rejected in a social situation
> may worry about appearing stupid, awkward, or boring, or being viewed badly for blushing, stumbling over words
> often avoid social situations, and when it cannot be avoided, they experience significant anxiety and distress
> physical symptoms
» rapid heart rate
» nausea
» sweating
» full-blown attacks when confronting a feared situation - Agoraphobia
> fear of public spaces, where escape seems impossible
> such places might be queues, public transport, crowded open spaces, outside a ‘safe’ place, an enclosed space
> experience fear, anxiety and real distress when enduring them
> the individuals with agoraphobia will seek to avoid triggering places which can disrupt their everyday life and cause significant impairment to the individual’s social and working life, making them unable to visit family and friends, commute to work or perform errands - Haemophobia
> an irrational fear of blood, but can also extend to needles injections or other invasive medical procedures
> individuals with blood phobia may actively avoid receiving injections, or situations and occupations which involves exposure to blood, such as visiting a hospital
> homophobes are known to experience an increased heart rate, combined with a drop in blood pressure when they see blood
> this physiological response can often lead to fainting - Koumpounophobia
> fear of buttons
> individuals cannot bear to touch buttons, or even look at them - Cynophobia/animal phobias
> commonly include dog, insect, bird and spider phobias
> individuals would again avoid contract with these animals
> experience distress or a panic attack of faced with them
> case study: Kimya
» female aged 39
» Kimya has been afraid of birds for as long as she can remember
» she has no idea what caused her extreme anxious reactions towards them
» Kimya cannot bear to even look at photographs of birds
» she finds the sound of birds flapping their wings particularly upsetting
» the thought of looking at or having to touch feathers makes her feel sick
» Kimya avoids places where she might be exposed to birds such as town centres, beaches or woodlands, which limits her social life
4
Q
First measures for anxiety disorders
A
Blood-Injury Phobia Inventory (BIPI)
- Away of measuring haemophilia
- A self-report measure
- Comprises 18 possible situations involving blood and injections to find cognitive, physiological and behavioural responses
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> eg situation: when I see blood on my arm or finger after pricking myself with a needle
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» eg cognitive response
»> I don’t think I will be able to bear the situation
»> I think I am going to faint
»> I think that something bad is going to happen to me
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> rate on a scale of 0 to 3 the frequency of each symptom
» 0 - never
» 3 - always - Individuals are asked to evaluate different reactions that might occur to them in each
5
Q
Second measure for anxiety disorders
A
Generalised Anxiety Disorder 7 (GAD-7) questionnaire
- Measure the severity of anxiety
- Has 7 items, eg:
> ‘Feeling nervous, anxious or on edge’
> ‘Being so restless that it is hard to sit still’
> ‘Feeling afraid as if something awful might happen’ - Participants also score between 0 and 3 for each item
> the scores in this test refer to the frequency of occurrence of symptoms
» 0 - not at all
» 3 - nearly every day - A screening test often used to enable further referral to a psychiatrist or counsellor rather than providing the level of detail needed for a formal diagnosis
> typically used by general practitioners and in primary care settings rather than by specialists
6
Q
Evaluation for measures of anxiety disorders
A
- Good concurrent validity
> Both GAD-7 and BIPI have been shown to have good concurrent validity with other measures
> valid and reliable instruments for assessing anxiety and blood phobia respectively - Self-report
> both measures rely on the accuracy of the individual’s self-reporting of symptoms
> if a person is having a particularly ‘bad’ day ( perhaps they have accidentally cut their finger that morning), then their BIPI score might be distorted by this
> hence, this can be said to have response bias
7
Q
Issues and debates for measures of anxiety disorders
A
- Psychometric assessments
> both measurement tools described here can be considered to be psychometric assessments
> this means they analyse one dimension of a person’s thinking, behaviour and emotions, for example, towards blood in the case of BIPI
> this type of assessment can be controversial
» relies on a single quantitative measurement of what is actually a complex and all-consuming lived experience for individual sufferers
»> hard to get a precise representation of thinking, behaviour, and emotions as it is a numerical data
» some psychologists might feel that these assessments alone do not tell us enough about what it is like to have a specific phobia, and how symptoms may change over time and with treatment - Cultural bias
> can affect the diagnosis of phobias
> there are cross-cultural differences in the diagnosis of social phobia.
» in North America, agoraphobia is a well-known, recognised disorder, but in Southeast Asian countries, it is rarely diagnosed
> these differences may relate to how different cultures comprehend independence and self-sufficiency or social interdependence and collectivism
> in cultures where individuals derive their sense of well-being and reassurance from those around them rather than in competition or contrast with others, diagnostic rates of social phobia seem to remain low - Reductionist
> these psychometric tests rely on a single quantitative measurement of what is a rather complex experience for patients
> they do not take qualitative data into account such as what it is like having a phobia
8
Q
First possible cause of phobias
A
Behavioural (classical conditioning, Watson & Rayner, 1920)
- One behavioural explanation for phobias is based on classical conditioning.
> an individual may develop a phobia of a harmless (neutral) stimulus if it is paired with a frightening experience
> for example, a person might develop agoraphobia following an assault or mugging in public - Watson and Rayner (1920)
A. Background
> used the principles of classical conditioning to create a phobia in a young boy
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B. Sample
> a normal, healthy 11-month-old infant known as ‘Little Albert’
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C. Research method
> Case study
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D. Procedures
> Prior to the conditioning, he was shown a range of different stimuli.
» These included a white rat, a rabbit, a dog, a monkey etc.
> He reacted normally and neutrally throughout with no outward signs of fear.
> The white rat was chosen as the neutral stimulus (NS).
> They also placed a metal bar above and behind Albert’s head and struck it loudly with a hammer.
» This was the unconditioned stimulus (US) as it produced an unconditioned response of fear (UCR) in the boy.
> The next phase was conditioning.
» When Albert was shown the rat, he began to reach for it, but just as his hand touched the animal, the researchers made a loud noise by striking a hammer against a metal bar just behind his head.
»> Understandably this made the infant very distressed.
» Watson and Rayner repeatedly paired the loud noise with presentation of the white rat over several trials one week after the initial trial.
» Eventually, Albert only had to see the rat and he began to demonstrate a fearful response (crying, trying to move away from it).
» The white rat becomes a conditioned stimulus (CS), producing a conditioned response of fear (CR).
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E. Results
> The researchers wanted to see if Albert’s fear of the rat was generalised to other similar-looking animals or items.
» When presented with a rabbit, he also had a similarly distressed reaction.
> These results suggested that fear could indeed be learned through classical conditioning.
9
Q
Second possible cause of phobia
A
Psychoanalytic (Frued, 1909)
- Frued suggested that anxiety and fear can result from the impulses of the id, usually when it is being denied or repressed.
> id is based on the pleasure principle and seeks immediate gratification. It is an instinctive or impulsive behaviour. - Phobias are one way this internal conflict can manifest in human behaviour.
> According to Frued’s theory of psychosexual stages, such sources of conflict are common at different times in our development.
> The phobic object comes to symbolise the conflict typical of the stage. - Frued suggested that phobias are defence mechanisms against anxiety created by any unresolved conflict between the id and the ego, usually when the id is denied.
> Ego is based on the reality principle that finds middle ground between id and superego which allows rational delayed gratification.
» The ego uses displacement to rechannel anxiety to another ‘thing’ that symbolises the phobic stimulus so that they become fearful of that instead.
> Superego is based on the morality principle which pushes towards socially acceptable behaviour. - Freud (1909)
A. Background
> Offered an account of a boy who was suffering from a phobia of horses and a range of other symptoms in order to illustrate the Oedipus complex.
> Little Hans had a fear of horses, displaced from a fear of his father, which was a coping mechanism.
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B. Sample
> Hans
> A five-year-old Austrian boy whose father had referred the case to Freud and provided most of the case detail
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C. Case detail
> Hans met Freud no more than twice during the period of the study.
> When he was three, Hans had developed an intense interest in his penis. He frequently played with himself which angered his mother, who threatened to cut it off.
» This upset the boy and he developed a fear of castration.
> Around this time, Hans’ younger sister was born and his mother was separated from him in hospital. He also witnessed an upsetting incident where a horse fell down and died in the street.
> Quite soon after this time, Hans’ horse phobia emerged. He was particularly worried that he would be bitten by a white horse.
> Hans’ father felt this concern was related to horses’ large penises.
> Conflict began to emerge at this time between Hans and his father, who had begun denying him the chance to get into his parents’ bed in the mornings to sit with his mother.
> Hans’ phobia lessened as he reached age five. His father reported Hans had experienced two notable fantasies at this time.
» One was that he had several children of his own with his mother, and imagined that his father was in fact his grandfather.
» He also fantasised that a new plumber had come and removed his penis and replaced it with a new, larger one.
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D. Findings
> The anxiety Hans experienced was related to his castration fear from his mother’s threat and the banishment of Hans from his parents’ bed.
> Frued felt that the object of fear, the horse, represented Hans’ father.
» Hans was particularly afraid of white horses with black nosebands, which symbolised his moustached father.
» This shows that Hans had developed a phobia of his father as he feared his father would discover his fantasies but displaced the fear onto horses to generate a coping mechanism.
> Further evidence of the Oedipus complex came from the two fantasies which represented the dynamic of the three-way relationship between Hans and his parents.
» Hans’ fantasies were also a coping mechanism to reduce Hans’ phobia.
10
Q
Third possible cause of phobia
A
Biochemical/genetic (Öst, 1992)
- Öst’s explanation states that phobias to certain objects are genetically transmitted in our DNA as a survival method.
> This explanation suggests that we are born prepared to fear certain objects. - Öst considers the genetic explanation for phobias.
A. Participants
> 81 blood phobic and 59 injection phobic patients
> Compared with a sample of other participants who had been diagnosed with different specific phobias (animal, dental and claustrophobia)
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B. Procedures
> Participants underwent a screening interview with a clinician.
> They also completed a self-report questionnaire on the history and nature of their phobia, including discussing the impact the phobia had on their normal lives.
> They are asked to give ratings to particular situations which might trigger a fearful response.
> Participants also underwent a behavioural test.
» The blood phobics were shown a 30 minute silent colour video of surgery being performed.
» They were told not to close their eyes but to try to watch for as long as they felt they could.
» The experimenter tracked gaze direction and if the participants looked away or stopped the video using a remote, the test would be terminated.
» The injection phobic test was ‘live’ and involved 20 steps, from cleaning a fingertip to performing a finger prick.
» Each step was described to the subjects, who had to say whether or not it was okay to perform.
» If they said ‘no’, the test ended.
> Participants also completed a questionnaire on their thoughts during the test.
> They have their blood pressure and heart rate monitored.
» This is because the fainting associated with these phobias has been found to be related to changes in blood pressure and heart rate.
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C. Measures
> A score relating to the percentage of maximal performance, for example, how long they watched the video.
> The experimenter’s rating of the patient’s fainting behaviour.
» 0 = no fainting
» 4 = fainting
> A self-rating of anxiety.
» 0 = not at all anxious
» 10 = extremely anxious
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D. Findings
> The family histories showed that 50% of blood phobics and 27% of injection phobics had one or more parents with the same fear.
> Around 21% of the blood phobics also reported having at least one sibling who shared the disorder.
> A high proportion of the participants with blood phobia and injection phobia had a history of fainting when exposed to their respective phobic stimuli.
» 70% blood phobics and 56% of injection phobics.
» These results are much higher than those participants with other specific phobias or anxiety.
> The mean number of fainting instances was 10.8 in the blood phobic group and 7.7 in the injection phobic group.
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E. Conclusion
> There seemed to be a strong genetic link for these phobias, which are more likely than other phobias to produce a strong physiological response (fainting).
11
Q
Fourth possible cause of phobias
A
Cognitive (Di Nardo et al., 1988)
- Cognitive psychologists view the origin of phobias as involving the individual’s thought processes.
> Those with phobias are biassed in their reasoning (faulty idea) about what is harmful.
> This means that they are more likely to perceive ambiguous stimuli (like heights or spiders) as more threatening than would most other people.
> They may also have negative self-beliefs, such as that they would not cope with being exposed to the phobic stimulus. - Di Nardo et al. (1988)
A. Background
> A study which examined the origin of cynophobia, the fear of dogs.
> Prior to this study, much research on specific animal phobias had focused on fear of snakes, and findings about the origin of such phobias were very mixed.
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B. Participants
> A participant group of 14 dog-fearful and 21 non-fearful female college students.
> A sample of female psychology studens aged 18 - 21.
> 37 women took part in this study.
> Chosen from a larger student population as they either rated themselves highly fearful of dogs and reported anxiety on encoutering a dog in a live behavioural test (fearful participants), or rated themselves as not fearful and felt little anxiety in the test (non-fearful participants).
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C. Research method
> Individual structured interviews in order to obtain information on the aetiology or origin of the phobia.
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D. Aims
> To investigate whether particular unpleasant events known as conditioning events involving dogs were more common in cynophobes or non-cynophobes.
> To compare fearful and non-fearful participants’ expectations of physical harm and fear upon encountering a dog.
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E. Procedures
> In the interviews, the participants were asked to discuss frightening and painful encounters with dogs, their expectation of fear or harm coming to them in such an encounter and their estimate of the likelihood associated with this expectation.
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F. Results
> Conditioning events, i.e., upsetting or painful encounters with dogs were reported by 56% of fearful participants and 66% found in the non-fearful group.
> The majority of such events in both groups involved bites or scratches.
> All of the fearful participants expected to experience fear or come to harm during an encounter with a dog compared with a small minority of the non-fearful group.
» Thus, anticipation of harm occurring was far greater in the fearful group than in non-fearful participants.
> So, while non-fearful participants had a different expectation of what would happen when encountering a dog, painful experiences with dogs were common among both groups.
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G. Conclusion
> Factors other than conditioning events must affect whether or not these painful experiences will develop into dog phobia, such as the individual’s own interpretation and rationalisation of events.
12
Q
Evaluation for the possible causes of phobias
A
- Case study
> Both the studies by Watson and Rayner, and Freud were case studies.
» This means we cannot reasonably generalise about the the acquisition of phobias from Little Albert’s or Hans’ experiences alone.
> However, Watson and Rayner conducted a number of trials using different stimuli to check whether Albert was a particularly fearful boy and control for any changes that occurred during the study.
» As Albert appeared healthy and confident, it may well be that phobias could be acquired by other children in the same way. - Validity
> Frued’s study lacked objectivity as he was a friend of Hans’ father, who also provided him with the case study detail.
» This research lacks validity as it may be subject to bias in an attempt to fit Freud’s existing theories about the subconscious and psychosexual stages.
> In comparison, the research by Öst et al. and Di Nardo et al. could be considered more objective, because they both used standardised behavioural tests and interviews with larger groups of participants.
» Their findings could be generalised more easily and had better levels of control.
» However, both studies were cross-sectional and did not consider the different participant’s experiences in depth. - Applicable to real life
> The studies in this section are directly applicable to real life.
> In understanding how phobias are acquired, the right method of treatment can be selected.
» In the study by Di Nardo et al., conditioning events may well play a role in developing a phobia of dogs; however, they do not seem to be the only explanation.
» Therapies for treating phobias which rely on cognitive techniques have a good success rate, which supports this explanation of phobia acquisition.
13
Q
Issues and debates for possible cause of phobias
A
- Nature explanations
> Help us consider the merits of different theories about what causes phobias.
> Biological explanations such as Öst et al. rely solely on genetic factors to account for the prevalence of fear, such as in blood phobia. - Nurture explanations
> The behaviourist account relies entirely on conditioning events which are a product of our environment.
> Although Little Albert was born a happy, confident boy, he was conditioned by his experience to fear rats; purely a result of his nurturing. - Ethical issues
> Both studies by Watson and Rayner and Freud use children as participants.
> Interestingly, both pieces of research were conducted on the early part of the twentieth century, where ethical issues were not of as such significant concern as they are today.
> Little Albert underwent a traumatic experience in being classically conditioned to fear rats; he was visibly upset and this was taken as a successful measure of the training.
> Although Freud was not directly involved with Hans, there are also questions around the boy’s consent in this study. - Determinism
> The behaviourist explanation of phobias is deterministic and states that a conditioning event (such as the training administered by Watson and Rayner) will produce a conditioned response of fear in individuals.
> However, the research by Di Nardo et al. counters this assertion, through evidence that conditioning events are common to both fearful and non-fearful individuals, and that there must be more complex explanations for our behaviour. - Reductionist
> Both the behaviourist and biological explanations of phobia acquisition can be considered reductionist.
> Watson’s explanation for Little Albert’s rat phobia relies entirely on his classically conditioned experience.
> Öst et al. look only at a specific biological explanation for blood phobia: the genetic link. - Holistic
> Cognitive theory used by Di Nardo et al. considers that conditioning events may have a role in causing phobic responses, yet emphasises this cannot be the only explanation because non-fearful individuals also have bad experiences with the animals.
> A more holistic explanation would consider the range of experiences, thinking and environment of the individual.
» This is more evident in Freud’s case study of Hans, who takes into account Hans’ fears, dreams, conversations and fantasies over a number of years to trace the origin and resolution of his horse phobia.
» Use of longitudinal research in this way can build an in-depth picture of a participant’s experience which can help us understand causal factors in specific phenomenon, such as the development of phobias.
14
Q
First treatment of anxiety disorders
A
Systematic desensitisation (Wolpe, 1958)
- A way of reducing undesirable resposes to particular situations.
> This makes it particularly an appropriate way of managing phobic reactions. - Its principles are based within behavioural psychology, namely it holds the assumption that nearly all behaviour is conditioned response to stimuli in the environment.
- If a phobia can be learned as in the case of Little Albert, then it can also be unlearned.
> Systematically desensitising a patient requires that a once frightening stimulus should eventually become neutral and provoke no real anxiety. - Wolpe introduced the idea of ‘reciprocal inhibition’, which is the impossibility of feeling two strong and opposing emotions simultaneously.
> The key to unlearning phobic reactions through systematic desensitisation is to put the fearful feelings associated with a phobic stimulus directly in conflict with feelings of deep relaxation and calm. - A therapist practising systematic desensitisation follows particular stages:
A. Teach patient relaxation techniques.
> These can be progressive muscle relaxation exercises, visualisation, or even anti-anxiety drugs.
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B. The patient and therapist work together to create an anxiety hierarchy.
> This is a list of anxiety-provoking situations relating to the specific phobia that increase in severity.
> The list is unique to the individual who works through in vitro or in vivo exposure to each stage in turn.
» in vitro: instances where exposure to the phobic stimulus is imagined, such as through a visualisation exercise
» in vivo: instances when the individual is directly exposed to the stimulus in real life
» Example:
»> Stage 1: Looking at a drawing of a spider
»> Stage 8: Holding spider in their own hand
> At each stage of the anxiety hierarchy, the patient is assisted to remain in a calm, relaxed state using their chosen technique. - Principles of classical conditioning linked to systematically desensitisation
> As the two emotions of fear and calm are incompatible, the fearful response to the stimuli is gradually unlearned and will no longer produce anxiety in the patient. - Research evidence to support the effectiveness of systematic desensitisation in treating phobias such as agoraphobia (Agras, 1967) and fear of snakes (Kimura et al., 1972).
> However, since the 1970s and 1980s, this form of therapy has declined in popularity and other treatments which involve more direct forms of exposure are now more commonly used.
15
Q
Second treatment of anxiety disorders
A
Applied tension (Öst et al., 1989)
- Involves applying tension to the muscles, in an effort to increase blood pressure throughout certain areas.
> Blood phobia in particular is associated with drops in blood pressure and fainting.
> By training individuals with blood phobia to increase muscle tension, the aim is to reduce instances of fainting and other unpleasant responses. - Öst et al.
A. Sample
> 30 patients that were outpatients at the Ulleriker mental hospital
> They were either referred by physicians or applied for treatment themselves after reading an article in the local newspaper.
> Participants were all otherwise healthy individuals with no other psychiatric problem in need of immediate treatment.
» Have no psychotic or organic symptoms.
» Have no heart or lung disease.
» If any anxiolytic drugs were used, the intake was to be constant throughout the time of the study.
» Not to receive any other kind of psychological or psychiatric treatment during the study.
> Between the ages of 18 and 60.
> 19 women and 11 men.
> With phobia of blood, wounds and injuries for a minimum of one year’s duration.
> Not able to watch the films shown below for more than 20 minutes.
> Express a willingness to participate in the study for a period of 3 months.
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B. Aims
> To establish which of these was the most effective treatment.
> To see whether applied tension could produce quicker improvements for phobia patients.
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C. Experimental design
> Independent measures design
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D. Treatment
> Those undergoing applied tension had five sessions.
> Those undergoing applied relaxation had nine sessions.
> Combined groups had ten sessions.
> Each session lasted between 45 and 60 minutes.
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E. Prior to commencing treatment, patients are assessed by :
@ Self-report measures
> Mutilation Questionnaire
» Self-rating of the patients’ degree of blood phobia.
» 30-items to be rated true or false.
> General measure of the patients’ phobias
» Fear Survey Schedule-III
»> Items: open wounds, receiving injections, seeing other people injected, human blood, animal blood…
»> Scores ranged from 8 - 40.
> Behavioural test
» Patients rated their degree of eperienced anxiety or discomfort on an 11-point (0 - 10) scale, every 2 minutes coinciding with the blood pressure measurements.
> ‘Thoughts during the test’ scale
» Patients filled out immediately after the end of the behavioural test.
» Constructed by the authors.
» Scale consists of 5 negative and 5 positive self-statements.
» Patients rate on a 0 - 4 scale on how often each thought occurred during the test.
@ Behavioural measures
> To assess the patient’s overt behaviour when confronted with blood stimuli.
> A 30-minutes colour videotape was shown at a distance of 2m, using a Sony videocasette recorder and a Beocord 26’’ video monitor.
» The tape was silent and consisted of four different thoracic operations containing large amounts of blood.
» The patient was instructed to watch the film for as long as she or he possibly could, without closing their eyes or looking away.
» They were told that this was a very important part of the assessment, that they had to do their very best and watch it for at least 5 minutes.
> To terminate the film, if it should be too uncomfortable, the patient could just press a button.
» There are two passive ways to end the test:
»> Looking away or closing the eyes, or
»> Fainting
» Whether either of these was used was determined by the experimenter who was present in the room with the patient.
> The behavioural measures obtained from this test were:
» The time (0 - 30 minutes) that the patient could watch the film, and
» The experimenter’s rating (0 - 4) of the patient’s fainting behaviour.
»> 0 - no reactions at all
»> 4 - the patient actually fainted and did not respond when talked to
@ Physiological measures
> Heart rate, blood pressure, and skin conductance level (SCL) were assessed.
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F. Pretreatment procedures
> When a patient was referred to the project for treatment, he or she was first mailed the Fear Survey Schedule-III, and Mutilation Questionnaire to fill in.
> Interview took about 90 minutes and its main purpose was to ascertain the patient’s suitability for the study and to conduct a behavioural test.
» The first part of the interview concentrated on letting the patient describe his or her phobic problems and getting information relevant to the inclusion criteria.
> After the baseline period had ended, the patient was informed about the film to be shown and instructed what to do during this presentation.
» This took 4 minutes and was followed by the film test described above.
> Subsequent to the patient turning the film off or watching the entire film, a post-baseline period was recorded.
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G. Applied tension treatment procedures
@ Session 1
> During the first session, a brief behaviour analysis was done followed by presentation of the method and its rationale.
> Care was taken to tie the characteristics of the method to the individual patient’s usual type of reactions to blood stimuli.
> The tension technique was then demonstrated to the patient who practised it supervised by the therapist.
> Patients were instructed to learn to tense their arm, chest and leg muscles until they experienced a feeling of warmth rising to their face.
» This is usually 10 to 20 sets.
> Then the patient lets go of the tension and returns to the starting level, but does not relax further.
> After a pause of 20 - 30 sets, the patient does the tension again, and then releases it.
> This procedure is repeated 5 times, and as a homework assignment, the patient is instructed to perform 5 tension-release cycles 5 times a day.
@ Session 2
> The application phase of the treatment started once the participants had mastered the technique.
> The patient was shown a series of slides of wounds, injuries, blood etc.
» This is to teach the patient to recognise the earliest sign of a drop in blood pressure and to apply the tension technique to reverse it.
@ Session 3
> The showing of slides continued during session 3, and 32 slides were used altogether.
@ Session 4
> The patient was accompanied to the Blood Donor Center to give him or her an opportunity to practice applying the tension technique while watching others donate blood, and while having a blood sample withdrawn oneself.
@ Session 5 (final)
> The patient was brought to the Department of Thoracic Surgery at the University Hospital to practice his or her coping skill while observing a thoracic operation, example, open-heart or lung surgery.
> The fifth session ended with a review of the progress accomplished by the patient so far, and a description of the maintenance program that the patient was expected to follow for the next 6 months.
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H. Applied relaxation treatment procedures
> Use progressive muscle relaxation technique during exposure to the same stimuli.
@ First session
> The coping rationale and structure of the treatment was presented.
> The treatment started with progressive relaxation with tension-release of the muscles.
@ Sessions 1 and 2
> The muscle groups were divided into two parts and gradually introduced.
@ Session 3
> The release-only version was intriduced.
@ Session 4
> Cue-controlled relaxation was introduced.
@ Sessions 5 and 6
> DIfferential relaxation was worked through.
@ Session 7
> Teaching the patient rapid relaxation.
@ Session 8 and 9
> Devoted to have the patient practice applying the coping skill while watching slides of wounds etc and while visiting the Blood Donor Center.
» These two sessions are similar to sessions 3 and 4 in applied tension.
@ Session 9
> Ended with a review of the progress made and description of the maintenance program as in the applied-tension condition.
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I. Combination of applied tension and applied relaxation (COMB)
> Same as applied relaxation with the addition of one session of teaching the patient the tension technique.
> This was inserted between sessions 7 and 8 of the applied relaxation program, making a total of 10 sessions for this condition.
> Throughout the treatment period, the patients were given homework assignments to practice and record each day, corresponding to the content of the preceding session.
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J. Post-treatment procedures
> 1 to 3 weeks after completion of the therapy, patients received the questionnaires to fill in and were telephoned and scheduled for an interview.
> During this interview, the patient was asked how she or he experienced the effects of treatment.
> The patient then went through the behavioural test as at pretreatment.
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K. Follow-up procedures
> Six months after the post-treatment assessment, the patients were mailed the questionnaires and telephoned to schedule an interview.
> During the interview, the patient was asked how she or he was experiencing the phobia, whether there had been any confrontation with the phobic stimuli etc.
> This was followed by the patients going through the behavioural test as the pre and post-treatment assessment.
> The behavioural test took place on the average 7.1 months (range 6 - 9) after the post-treatment assessment.
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L. Results
> Self-rating of anxiety
» All treatment groups improved significantly after treatment.
> Thought index
» Before treatment, the patients had on the average as many negative as positive thoughts during the behavioural test.
> After treatment, there was a marked dominance for positive thoughts.
> All groups improved significantly after treatment. However, the changes during follow-up were small and non-significant.
> Thought ratio
» This measure is based on the same self-ratings as the thought index but is the ratio between the number of positive thoughts and the total number of thoughts.
> Mutilation Questinnaire
» All groups showed a significant treatment effect, and on the whole maintained their gains at the follow-up assessment.
> There were similar improvements across all groups, with around 73% of participants across all groups showing a noticeable improvement in their behavioural and physiological responses to blood.
> Since applied tension had been at least as effective as the other treatments in around half the time, the experimenters suggested it may be the most appropriate treatment choice for blood phobia.
