Specific Phobia

LPT Gondar Mental Health Group

www.le.ac.uk

Introduction

• Phobos – Greek God of fear.

• Prevalence - Phobias are very common - Lifetime prevalence rate for clinically diagnosable phobias is about 12%. - 60% of the population usually admit to experiencing ‘unreasonable fear’ at some point in their lives

• Historical Middle Ages – Syphilophobia & Plague Phobia 1960’s & early 70’s. – Seligman’s theory of Biological Preparedness and development of Exposure Therapies 1980’s & 1990’s. – Increasing understanding of role of cognitive factors in aetiology and maintenance of phobias. Present. Awareness of multiple acquisition mechanisms – traumatic events, dispositional factors such as increased disgust sensitivity or neither.

ICD 10

• F40 Phobic Anxiety Disorders – F40.0 Agoraphobia

– Without panic disorder – With panic disorder

– F40.1 Social phobia – F40.2 Specific (isolated) phobias – F40.8 Other phobic anxiety disorders – F40.9 Phobic anxiety disorder, unspecified

• F41 Other Anxiety Disorders – F41.0 Panic disorder (episodic paroxysmal anxiety)

– F41.1 Generalised anxiety disorder – F41.2 Mixed anxiety and depressive disorder – F41.8 Other specified anxiety disorders – F41.9 Anxiety disorder, unspecified

Definitions

• Agoraphobia – Anxiety about being in places or situations from which escape might

be difficult (or embarrassing) or in which help might not be available in the event of having an unexpected or situationally-predisposed panic attack or panic-like symptoms.

• Specific phobia – Persistent and irrational fear of a specific object or a specific situation.

• Social phobia – Persistent fear of one or more situations in which the person is

exposed to possible negative evaluation, criticism or rejection by other people. Person often fears they might behave in a way that will be embarrassing.

Specific phobia

• Persistent and irrational fear of a specific object or a specific situation.

– A compelling desire to avoid the object or situation causing

considerable inconvenience.

– On exposure to the feared stimulus a fear reaction follows immediately.

– Person realises that the fear is disproportional and irrational.

– Person usually free of symptoms if they are neither in nor anticipating a phobic situation.

– The person may dismiss the fear when in a safe place but still believe they are in danger when faced by the feared stimulus.

Phobias

• Specific phobia

–Animal

–Natural environment

–Blood, Injection, Injury

–Situational

–Other – rare / atypical phobias

–Fear of fear (Rachman and Bichard 1988)

–DSM-IV criteria page 44

Definitions

• Alektorophobia - Fear of chickens. • Algophobia - Fear of pain. • Alliumphobia - Fear of garlic. • Allodoxaphobia - Fear of opinions. • Altophobia - Fear of heights. • Amathophobia - Fear of dust. • Amaxophobia - Fear of riding in a car. • Ambulophobia - Fear of walking. • Amnesiphobia - Fear of amnesia. • Amychophobia - Fear of scratches or being scratched. • Anablephobia - Fear of looking up. • Ancraophobia - Fear of wind. • Androphobia - Fear of men. • Anemophobia - Fear of air drafts or wind. • Anemophobia - Fear of wind. • Anginophobia - Fear of angina, choking of narrowness

Associated features

• rates of 65% of co- morbid disorders- PTSD and social phobia most prevalent

• Also substance misuse, depression

• More common in women than men

Developmentally Normal Fears

Age Normal Fear

Birth- 6 Months Loud noises, loss of physical support,

rapid position changes, rapidly

approaching other objects

7-12 Months Strangers, looming objects, unexpected

objects or unfamiliar people

1-5 Year Strangers, storms, animals, dark,

separation from parents, objects,

machines loud noises, the toilet

6-12 Year Supernatural, bodily injury, disease,

burglars, failure, criticism, punishment

12-18 Performance in school, peer scrutiny,

appearance, performance

Assessment

• Again has to be thorough especially to find out about co morbid disorders

Pathogenesis

• Amygdala- the central nucleus on the amygdala important. When a stimulus is paired with a threat, on subsequent exposure to the stimulus an increased starle rsponse is elicited- the ‘fear potentiated startle’ – lesion of the nucleus stops this response

Aetiological models page 51

• Modified conditioning model- similar to classical conditioning but in order to explain the absence of a conditioning event it suggests that the conditioning event is forgotten

• Non associative models- suggest that certain intrinsic fears are part of normal development and that specific phobias represent the failure of habituation

Pharmacotherapy

• Not much evidence for efficacy

In small groups (3 – 4)

• Think of a phobia that you hold yourself or that someone you know well has. What do you / they avoid as a result of this phobia?

How reasonable does it seem to have this fear?

In what ways does it seem to be useful to avoid the situation/ stimulus?

How would you feel about having CBT to get rid of it? If you feel unwilling, what would need to change to make you seek help?

Specific phobia

Simple phobias are widespread in the population. 12% meet lifetime diagnosis.

Easy to avoid hence people do not seek treatment. People sometimes seek help so as not to pass on the fear to their children.

Most frequent in clinical practice are: - animals, enclosed spaces, height, blood, medical interventions, thunderstorms, flying, darkness, dentist, disease.

Claustrophobia - fear of being trapped in an enclosed space. Can cause problems in lifts, lavatories, shower cubicles, cellars, sitting in the back of a two door car.

Blood phobia. Very common in the population although more so in children. Most phobias result in autonomic arousal whereas blood phobias cause the opposite and nausea and fainting are common. Might more appropriately be seen as a fainting phobia.

Fear is of object itself - not of having a panic attack (as in panic disorder), of humiliation (as in social phobia) or contamination (as in OCD).

Age of onset and sex difference

• Mean Onset Age

Social phobia Agoraphobia Simple phobia

Marks and Gelder (1966) 19 (25) 24 (84)

Shafar (1976) 20 (20) 32 (68)

Amies et al (1983) 19 (87) 24 (57)

Thyer et al (1985) 16 (42) 27 (115) 16 (152)

Persson & Nordlund (1985) 21 (31) 27 (37)

Solyom, Ledwidge & Solyom (1986) 17 (47) 25 (80) 13 (72)

Ost (1987) 16 (80) 28 (100)28

Percentage of female patientsSocial phobia % Agoraphobia % Simple phobia%

Marks and Gelder (1966) 60 (25) 87 (84)

Shafar (1976) 55 (20) 87 (68)

Amies et al (1983) 40 (87) 86 (57)

Thyer et al (1985) 52 (42) 81 (115)

Solyom, Ledwidge & Solyom (1986) 47 (47) 86 (80) 78 (72)

Ost (1987) 65 (80) 87 (100) 80 (190)28

Mean Onset AgeSimple phobia

Animal phobia 7

Blood phobia 9

Dental phobia 12

Claustrophobia 2028

From Ost (1987)

Phobias: a differential diagnosis

• In phobias, anxiety is elicited by a single stimulus (or may have a phobia of several stimuli)

• Distinguishable from:

Panic / agoraphobia – pervasive anxiety, not about a single stimulus

Panic – variety of situations act as a trigger, focus primarily on bodily symptoms, not an external stimulus

Social phobia – negative evaluation by others vs. a specific stimulus

PTSD – intrusive symptoms and fear as consequence of a life-threatening stressor

OCD – fear is the content of the situation (e.g. contamination) not the stimulus itself

Acquisition & maintenance of fears

• Learning theory – Fear acquired by classical conditioning and

maintained by operant conditioning

• Classical conditioning – CS + UCS CR

birds + noise fear of birds

• Operant conditioning – Avoidance prevents extinction occurring and

also produces anxiety reduction which reinforces

Assessment 1

• Starts in first session and continues throughout treatment. • Aims:

– To agree a formulation of the target problem with the patient. – To gain sufficiently detailed information about factors

maintaining the problem to be able to design a treatment plan.

• Modes of assessment – Cognitive-behavioural interview – Self-monitoring – Self-report – Information from other people – Direct observation (role play or behavioural tests) – Assessment scales (Fear Questionnaire, Fear of Vomiting scale)

Assessment 2

• Brief description of problem

• Development: • precipitants, time course, predisposing factors

• Description of problem behaviour: • behavioural, cognitive, affective, physiological

• Contexts and modulating variables: • situational, behavioural, cognitive, affective, interpersonal, physiological

• Maintaining factors: • situational, behavioural, cognitive, affective, interpersonal, physiological

• Avoidance • Coping resources and other assets • Psychiatric and medical history • Previous treatment • Beliefs about problem • Engagement • Mood/mental state • Psychosocial situation

– Family, psychosexual relationships, accommodation, occupation, relationships, hobbies

• Preliminary formulation

Behavioural factors

Avoidance leads to a short term decrease in anxiety which is why it is repeated.

Avoidance maintains phobia in the long term by preventing new learning i.e. that predicted aversive outcomes do not inevitably occur.

Avoidance generalises to other similar situations.

Behavioural approaches to phobias

• Creating a fear hierarchy

• Exposure: graded vs. flooding

• Systematic desensitisation

Fear Hierarchy

• List all the cues and situations that cause anxiety – Information from detailed assessment

• Attribute SUDs rating to each one – Subjective Units of Distress

‘0’ No anxiety - ‘100’ Maximum possible anxiety

• Create a hierarchy of increasingly fearful situations – Lots of items in upper ranges – 30+ SUDS – Items must be ones that the person can actually practice

frequently – SUDS rated on anxiety when safety behaviours and avoidance

cannot be used – Hierarchy is flexible. Items can be added or removed

Exposure 1

Key assumption: anxiety is maintained by avoidance

• Person exposed to cues that evoke anxiety until they realise that their fears do not come true and their anxiety reduces: habituation occurs

• Exposure may be in-vivo or imaginal.

• Imaginal exposure used when in vivo not practical because:

– Cues are internal (memories, thoughts)

– Cues not immediately available (flight phobia)

– Cues cannot be evoked (fear of death of family member)

– Patient who is too anxious to start with in vivo

Anxiety during exposure

100

Anxiety

level

0

Catastrophe What the patient believes will happen

What the therapist

predicts will happen

Exposure starts Ends

Time

Escap

e

Exposure 2

• Preparation. – Explain rationale and procedure. – Prepare for high levels of initial anxiety.

• Creation of exposure hierarchy. – List of increasingly fearful situations with ‘SUD’ ratings.

• Initial exposure. – Patient exposed until SUD rating dropped by 50% and

habituation occurring. Otherwise anxiety response will be strengthened. Lengthy first session.

• Repeated exposure. – Patient exposes self daily. Continues with an item until it

evokes no anxiety and then moves up hierarchy. Keeps records of progress.

Exposure 3 • Exposure is most effective when it consists of

clearly specified tasks that 1. Evoke anxiety

2. Are prolonged until habituation takes place 3. Are repeated until fear response decreases

• Problems with exposure 1. Exposure task does not include the relevant anxiety provoking

cues 2. Patient engages in subtle form of avoidance such as distraction and does not engage with anxiety provoking cues 3. Exposure is too short (SUDS do not drop by 50%) or carried out too infrequently.

Treatment for specific phobia

• Additional considerations: Massed practice Establishing generalisation Homework compliance Therapist fears

Creating a fear hierarchy Hierarchies used to grade exposure to feared scenarios

or stimuli.

Develop a scale of feared scenarios relating to the phobic stimulus – each with a SUDs rating from 0 – 100

Aim is to identify scenarios associated with a range of distress responses. May need to make suggestions if client finds this difficult

Focus on scenarios with SUDs ratings between 30 – 70

May be helpful to use a visual scale, or imagery

Start with a realistic goal – beware of unrealistic predictions by both therapist / patient

Fear hierarchy: some useful questions

What about thinking about putting yourself in that situation right now?

What would it be like if we looked at a picture of …..? How about talking about [stimulus] or imagining one in your

mind’s eye? What about if you stood at the door / in the middle of the room /

next to the exit (with feared stimulus in room)? Can you think of anything that would be a little less /more

terrifying than that? How much longer could you have managed to stay in that

situation? Would you feel more or less able to cope if someone was with

you? How about if there was an …… in the next room? If that situation is a 50%, can you think what a 40% might look

like?

Fear hierarchy, dog phobia example

Seeing a cartoon picture of a dog 25

Seeing a photo of a small dog 40

Seeing a photo of a big, black dog 60

Being on opposite side of a room to a dog (on a lead) 65

Being on opposite side of room to a dog (no lead) 80

Sitting next to a dog (on lead) 90

Sitting next to a dog (off lead) 95

Walking in the local park in morning (lots of dogs) 100

Exercise: creating a hierarchy for phobias

Client:

• Think of a phobia that you hold yourself, or that of a patient you are working with – or make one up

Therapist:

• Your task is to give your patient a rationale for exposure interventions for phobia, and to help them to construct a hierarchy of situations relating to their phobia. Rate each of these (SUDS 0 – 100)

• Discuss with your client where they think they could start on the hierarchy – realistic, small goals

Animal phobias

• Five first-order dimensions of animal fears: (Graham Davey)

• Predatory animals • Fear-relevant animals • Dry, non-slimy invertebrates • Slimy, wet-looking animals • Farm animals

Most feared animals: – 1. Snakes 8. Bee 15. Lizard – 2. Wasp 9. Eel 16. Beetle – 3. Rat 10.Horse 17. Worm – 4. Cockroach 11. Mouse 18. Moth – 5. Spider 12. Slug 19. Pig – 6. Maggot 13. Dog 20. Cow – 7. Bat 14. Goose

Disgust

• Spiders – why do people fear spiders? - Graham Davey – Conditioning?

– Biological preparedness?

– Disgust!

• Disgust emotion is a food-rejection response that has evolved to prevent contamination and the spread of illness and disease.

– Disease spread (cockroaches & rats)

– Food contamination (maggots & mice)

– Similar to primary disgust objects such as mucus (snakes, slugs & snails)

1 session treatments

Lars Goran-Ost

• Spiders, snakes, birds, wasps, blood-injury, injection, claustrophobia, flying

& numerous other specific phobias

• Exposure in-vivo, sometimes with modelling

Treatment of injection phobia 1

• Lars-Goran Ost Aim – To prick 10 fingers, to do 12 sub-cutaneous injections and 2-4

venipunctures during 1 session of prolonged exposure.

Behavioural analysis interview – To obtain a detailed description of patients behaviour in phobic situations as well as catastrophic cognitions when exposed.

– 50% have a history of fainting – Many fear the pain – Disgust at thought of needle penetrating the skin. – Fear that blood vessel that has been penetrated will not stop

bleeding. – Fear that needle will break off and wander around inside the

body.

Treatment of injection phobia 2 • Treatment

– Describe and demonstrate each small step Each time obtain pts permission to proceed Start with pricking fingers Obtain prediction of what will happen and belief that this will occur Demonstrate finger pricking and proceed Ask patient to rate degree of anxiety and pain and to compare this with the expectation Continue to subcutaneous injection when anxiety rating is less than 30. Explain the procedure – needle into fatty sub-cutaneous tissue. 1 in 3 chance of hitting a pain receptor Initially insert and remove. Then inject saline. May have to break this down into smaller steps. After 4-6 injections and anxiety rating below 30 then proceed to venipuncture

Explain the process and proceed

What about the cognitive bit?

Relatively neglected - outcome data from exposure studies suggests repeated, prolonged exposure is highly effective in treating phobias. 70 – 85% cases significantly improved (Roth and Fonagy, 2005)

Behavioural theory suggests fear is reduced by habituation and extinction, BUT underlying mechanisms unclear: behaviourists include cognitive variables to help explain this (self efficacy, emotional processing and perceived control)

Inclusion of cognitive factors may enhance motivation, effectiveness and generalisability of exposure tasks

A cognitive model of phobias

Phobic anxiety is a rational response to situations seen as dangerous, as a result of biases in perception, interpretation and memory

Behaviour has a key role in maintaining phobias, but key Tx. target is thinking. Behaviours make sense, given the beliefs that underpin them

Identification of idiosyncratic fear cognitions allows specifically targeted interventions

Key aim is to facilitate new understanding that feared stimuli are not / are unlikely to be dangerous (thus safety behaviours are unnecessary)

Key maintenance processes implicated in phobias

Anxious predictions: exaggerated estimates of harm/danger, and underestimation of coping / rescue (Beck et al, 1985)

Physiological arousal

Hypervigilance – for cues related to phobic objects, and to physiological symptoms

Safety behaviours – serve to prevent anxious predictions from being disconfirmed

Key cognitions involved in phobias

Overestimation of the probability of damage, harm, pain or injury

Overestimation of the consequences of damage, harm, pain or injury

Underestimation of coping

Underestimation of rescue factors

Secondary cognitions

Identifying key cognitions

• Make sure the patient understands the connection between thoughts, feelings and behaviour

• Socratic questioning and thought monitoring to identify relevant cognitions, including downward arrow. Have you got the “hot” thought?

• Help patient to be aware of their thinking biases – selective attention, catastrophisation etc

• Help patient to decentre and re-appraise cognitions. This may include: – Exploring the evidence for/against – Psychoeducation (e.g. airline safety records for

turbulence) – Impact of info processing style on information attended to

• Developing an alternative or balanced perspective on the basis of evidence – and rate conviction in new belief

The learning cycle: Key Questions

Observation What happened? What did I do/notice?

How did others react?

Reflection How can I understand this?

What did it mean?

How does it relate to my predictions?

Plan How can this be carried forward?

What are the practical implications?

What else do I need to know?

Concrete experience Mindfulness: Situation? Thoughts?

Emotions? Behaviour? Body State?

What are you interested in discovering?

Whether a catastrophic outcome actually occurs? Whether an outcome is as catastrophic as predicted? If and how a safety behaviour maintains distress? The implications of an alternative interpretation? What thoughts and images occur in the feared

situation? Whether secondary cognitions about having the

phobia are realistic? Whether secondary cognitions about coping are

realistic?

Maximising learning from behavioural experiments.

• Construct experiments that involve dropping all safety behaviours (use a graded approach if necessary)

Predictions must relate to danger not unpleasantness

The client decides how far to go

Continue testing the prediction until the client is satisfied

Preparing the patient for behavioural experiments

• Check out:

– What is the specific belief you are testing?

– Can the client find evidence / for against this view?

– Generate an alternative interpretation based on a review of the evidence

– Can they recognise alternative interpretations as feasible?

Assess safety behaviours

• Things people deliberately do or don’t do in order to prevent the perceived worst from happening

• Which safety behaviours:

– Are being used to prevent perceived harm?

– Prevent disconfirmation of catastrophic fears?

– Increase misinterpretations?

– Increase preoccupation and rumination?

Predictions and safety behaviours in phobias

Phobic stimulus Predictions (harm,

coping and rescue)

Safety behaviours

Heights If I stand near edge I’ll lose

it and fall. Image of self

dead on ground

Needles The needle will break in my

arm, the pain will be

unbearable, I’ll faint

Animals If I see a rat it will go for my

throat, rats always attack

Claustrophobia I’ll be trapped in here; I’ll

lose control

Vomit I can’t stand the sight /

smell of vomit. Seeing

vomit will make me ill

Going through the steps

Establish the

current belief

Behavioural

manipulation

to test the

two beliefs

Rate the

strength of

this belief

Establish the

alternative

belief

Rate the

strength of

this belief

Agree a

timeframe to

be sure that

either belief

has support

Assess the

outcome –

which belief

was right?

Revisit and

re-rate the

beliefs

If you have not taken all these steps, it is not

likely to work…

Exercise Taking turns as therapist, help your client to

develop a behavioural experiment relevant to their phobia. You already have a description of their difficulties – the experiment needs to target beliefs and safety behaviours

If doing a theory A/B experiment, make sure you have identified a target cognition and developed an alternative prediction (with belief ratings)

Does the experiment need to be graded? If so, develop clear and explicit stages

What subsequent behavioural experiment(s) might be needed to consolidate and generalise learning?

Feedback

• How did you get on? Were you able to construct an experiment?

• What was the experience like as the patient? Did you feel that you were willing to try the experiment?

• What have you learnt from doing this that will be helpful when treating phobias in clinical practice?

BEs and phobias: issues to consider

Very high anxiety – stay calm and encouraging (but don’t

buy into their predictions). Allow breaks if necessary – aim is to test predictions, not habituate to anxiety

Patient too scared to do the experiment:

Therapist modelling and grading of difficulty level, flashcards re. alternative perspective being tested and how fits with formulation,

motivational work

Avoidance of affect: no emotional processing /

discovery that anxiety is not harmful: discussion beliefs about experiencing emotion – & targeted BEs

Behaviour exposure and phobias: issues to consider

• Subtle safety behaviours – if anxiety persists, look out for monitoring, distraction, reassurance seeking, rushing through the expt.

Interpersonal maintaining factors

Co-morbidity

Generalisability

Provided by The Leicester Gondar Link

Collaborative Teaching Project

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