Lecture 4 - Specific Phobia

Question 1

Specific Phobia - Description (4)

Answer 1

• lasting and unreasonable fear caused by exposure to a specific stimulus. 60% of adults have a fear, but fewer have it cause interruptions to their daily routine.
• Excessive or irrational fear, avoidance of the situation or object or enduring it with great distress, physical symptoms of anxiety (dizziness, shortness of breath, heart rate), anticipatory anxiety.
• 12 month prevalence 7-9% in US, 6% in Europe, 2-4% in Africa, Asia, Latin America. Children – 5%. Adolescents – 13-17%. Females 2:1 diagnoses.
• Animal/environmental/situations/BII (blood injury injection)/other.

Question 2

Specific Phobia - Aetiology (5)

Answer 2

• most people can’t remember the ‘traumatic event’. 75% have them by 12yo, onset 7-9 years.
• Risk factors – temperamental (negative affectivity, behavioural inhibition); environmental (parental overprotectiveness, parental loss and separation, physical and sexual abuse, traumatic encounter); genetic (31% first degree relatives – encoded fears or modelling).
• Conditioning models – fear associated with a previously neutral stimulus. Cognitive and evaluative functions – latent inhibition (previous neutral experiences will inhibit the response and hinder association with UCS) and UCS inflation (aversiveness of the UCS enhanced by social learning)
• Modelling – observing someone else’s fear reaction. Negative information influencing fear response.
• Maintaining factors – avoidance (no opportunity to learn that the CS is not bad), cognitive biases (attentional bias towards threatening material, fast attentional capture, slow to disengage from threat, vigilance-avoidance pattern).

Question 3

Specific Phobia - Assessment (9)

Answer 3

• Fear Survey Schedule – 108 commonly feared objects or situations. Cannot distinguish between phobias and fearful controls and general anxiety.
• Anxiety Sensitivity Index – assessment of the fear of physical symptoms of anxiety.
• Phobic Stimuli Response Scales – five domains (social, animal, physical confinement, bodily harm, blood injection). Cannot identify specific phobia or determine severity. Validated in clinical sample.
• Disgust Scale – 7 domains (food, animals, body products, sex, body envelope violations, death, and hygiene). Condensing to core disgust, animal reminder disgust, contamination based disgust.
• Disgust Propensity and Sensitivity Scale – how quick it is felt, sensitivity, negative views.
• Self-Monitoring Diaries – fear cues, intensity, physical reaction, coping strategies.
• Behavioural Approach Test – enters feared situation and measured based on distance and response.
• Subjective Units of Distress Scale – how much distress is being caused.
• Risk Assessment – not a high risk for standalone specific phobias, but higher risk for comorbid anxiety and mood disorders, 1.5 more likely to have a substance abuse disorder.

Question 4

Diagnosis for Specific Phobias

Answer 4

Intense fear of a specific object or situation, with an almost always immediate fear response. The situation is actively avoided or endured with intense fear. The fear or anxiety must be disproportionate to the object or situation (taking culture into account). Fear must persist for at least 6 months, and cause significant distress or impairment.

Need to rule out other diagnoses, such as fear of the panic symptoms, fear relating to obsessions or traumatic events.

Question 5

DSM5 Changes for Specific Phobia

Answer 5

• removed the requirement that the individual must recognise that their fear is disproportionate.
• 6 month duration is extended to all ages.

Question 6

Medication for Specific Phobia

Answer 6

No FDA approved mediation. Benzodiazepines reduce subjective and physiological responses but have an increased risk of relapse. Antidepressants showed small improvement but not enough to be clinically significant. Cycloserine has been shown to accelerate fear reduction through memory consolidation but has increases in anxiety, confusion, dizziness, drowsiness, irritability, depression, muscular twitching. Not necessary for specific phobias.

Question 7

Evidence Based Treatment for Specific Phobia

Answer 7

• Level 1 Evidence for CBT, Level II evidence for self-help + medication.
• Exposure based treatments - more effective than waitlist, placebos, and non-exposure treatments (CT, PMR). Causes extinction of the fear response so that the association between the stimulus and the aversive outcomes is eroded.
• In vivo exposure is the gold standard for phobia treatment. Can do flooding in one session, but meta-analyses have suggested that multiple sessions allows for continued improvement after the treatment has ceased. Less reliance on safety behaviours, greater approach, lower SUDS than imaginal exposure according to BAT.
• Imaginal exposure – feared object is present only in the mind.
• Systematic desensitisation – imaginal exposure combined with PMR.
• Virtual reality headsets – simulate confrontation, can be useful for impractical in vivo phobias like flying phobia.
• Applied tension – exposure with muscle tension. Maintaining blood pressure – used for BII phobias, since they have a physiological response where HR and BP increase then decrease, leading to dizziness, headache, and fainting.
• Assessing treatment efficacy – Behavioural Approach Task (SUDS, distance, physiological correlates, observations, self-report). Measures discussed earlier, phobia relevant questionnaires, general anxiety questionnaires.

Question 8

Challenges in treating specific phobia

Answer 8

be very clear that clients will not be placed in objective danger.

• Cross-cultural considerations – higher rates in US and Europe than in Asian and Latin countries. Differences across cultures in fears – Western (burglars, getting lost etc.), Chinese & Nigerian (electricity and dangerous animals), Chinese (ghosts and deep water).
• Animal - -fear-irrelevant, fear-relevant, and disgust-relevant are relatively consistent across cultures. Fear scores are greater for disgust animals compared to fear-irrelevant. Indian people had less fear of disgust animals, while Japanese had most fear and for more animals.
• Safety behaviours are maintaining factors – ‘builder’s metaphor’ – you don’t know what will happen without the safety behaviours.
• The higher they start on the exposure hierarchy, the quicker the therapy works. Should overlearn which is good for maintenance and follow up.
• Exposure has high attrition rate – should do more cognitive sessions in order to normalise, address dysfunctional thoughts, and make them more receptive to exposure.
• If the therapist is also afraid, need to manage their own feelings, don’t ask someone to do something you are not willing to do.
• Predictions for behavioural experiments must be concrete and testable.
• Generalisation is key – clients need to incorporate behavioural experiments into their daily lives.