PsychInsights
1.4.1 Diagnostic criteria for anxiety disorders and fear-related disorders
(ICD-11 Criteria for disorder, Agoraphobia Specific Phobias and Measures GAD-7 / BPI)
↳ Example Study: Mas et al. (2010)
Generalized Anxiety Disorder:
Long term condition that is characterized by intense persistent and unreasonable anxiety about everyday life. Symptoms must persist for several months to be diagnosed. Symptoms include a general sense of apprehension and, excessive worries about family, health, finance, school, or work. Other symptoms include Physical muscle aches, pain, insomnia, and digestive problems. Behavioural restlessness and irritability, affective such as feeling nervous, and cognitive being unable to concentrate.
Generalize Anxiety Disorder Assessment (GAD-7):
A tool used as a screening test by GPs to see if further referral to a physiatrist is required. This is a seven-item questionnaire (it can also be used as a structured interview schedule) that measures the severity of anxiety, these include: “Feeling nervous, anxious or on edge” and “Feeling afraid as if something bad would happen” The responses will ask for scores between 0 – 3. 0: Not at all, 1: Several days, 2: More than half of the days, 3: Nearly every day.
Agoraphobia:
Definition - A fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong. The person will be afraid of experiencing specific negative outcomes like panic attacks or embarrassing symptoms in a public place. So whenever possible these situations are avoided and when needed to be entered, they are under extreme distress. Symptoms persist for several months and are severe enough to result in huge distress and impairment to normal functioning.
Specific Phobia (Blood-Injection-Injury / BII):
Specific phobia individual’s irrational and or excessive fear or anxiety that occurs consistently when exposed to, or in anticipation of, a specific stimulus such as certain objects, events, or animals. In this case, the exposure or anticipation of blood, injection, or injury, can cause increased blood pressure and heart rate. The fear and anxiety are disproportionate to actual danger and the phobic stimulus will be avoided or endured horrifically. Symptoms persist for several months and are severe enough to result in huge distress and impairment to normal functioning.
The Blood Injection Phobia Inventory (BIPI):
This is a self-report measure of the BII phobia. It lists 18 situations involving blood and injections involving themselves or others. Some items relate to situation anxiety: this shows person feels and behaves while CONFRONTING the situation. The other assesses anticipatory anxiety which is how they think feel and behave LEADING UP TO the situation.
EXAMPLE STUDY: MAS ET AL. (2010)
Researched 3 factors.
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To see if the BIPI could distinguish between those diagnosed with BII Phobia and those who weren’t.
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See whether the phobia was 1 dimensional or influenced by a range of stimuli (BII Phobia is not caused by just one medical procedure but a multitude of them.)
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find out whether the BIPI could identify a change in people with the phobia, because of the therapy.
They studied 39 participants and a control group matched with age/gender. The participants did the BIPI and Fear Questionnaire – which aimed to measure agoraphobic fear, social anxiety, and injection injury phobia. (Marks and Matthews 1979)
Results: BIPI has good concurrent validity. There was a strong positive correlation between the BIPI score and scores on the blood sub-section of the FQ. People with blood phobias obtained significantly higher scores on the BIPI than the control group.
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The genetic explanation
suggests that we are born prepared to fear certain objects. So, there are stimuli in the environment that may pose a threat to survival that we are more genetically set up to avoid.
EXAMPLE STUDY: ÖST (1992)
Ost carried out a study with 81 blood-phobic patients and 59 injection-phobic ones. They were compared to the sample of patients with other SPECIFIC phobias like animal, dental or claustrophobia.
Participants did a screening interview and a self-report questionnaire on the HISTORY and NATURE of their phobia; the impact of phobia on normal life and ratings of situations triggering a fearful response.
Both groups underwent a behavioural test: Blood phobics watched a colour video of thoracic surgery and injection phobics had a finger-prick blood test. (They were allowed to withdraw at any time)
Results of family histories found that:
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50% of blood phobia patients had one or more parents who also had blood phobia.
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27% of injection phobia had at least one parent with the phobia.
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21% of the blood phobia had at least 1 sibling with the phobia.
The following % had a history of fainting when exposed to respective phobic stimuli.
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70% of blood phobia patients
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56% of injection phobia patients
Overall, a strong genetic link between these phobias, which are more likely than other specific phobias to produce a strong physiological response (fainting).
PSYCHOLOGICAL – BEHAVIOURAL CLASSICAL AND OPERANT CONDITIONING:
Classical conditioning suggests that we can develop a phobia of harmless stimuli when paired with a frightening experience. Like after being assaulted you could develop agoraphobia.
EXAMPLE STUDY: WATSON AND RAYNER – LITTLE ALBERT (1920)
The researchers used the principles of classical conditioning to create a phobia in a 9-MONTH-OLD healthy infant, known as Albert. Before conditioning, he was shown a range of stimuli: dog, monkey, rabbit, rat and even fire (burning newspaper) Then they began conditioning and they used the white rat as the stimuli.
Albert's fear of the rat was generalized to other similar-looking animals or items. When presented with a rabbit he also had a similarly distressed reaction. This shows FEAR can be learned through classical conditioning.
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But to understand why phobias persist is due to operant conditioning (Learning through consequences, either rewards or punishments) Negative Reinforcement: it is the likelihood of repeating the behaviour, due to the removal of something negative or unpleasant.
Therefore, in terms of phobias, the avoidance of the phobic stimulus reduces the fear, so it is therefore rewarding, and the avoidant behaviour will be repeated.
PSYCHOLOGICAL – PSYCHODYNAMIC (FREUD):
Freud believed that, without therapy, people with phobias will never know why they have these irrational fears. This is because the reasons for these symptoms are stored below the level of conscious awareness, in the unconscious.
Id – Unconscious wishes and desires are held here; The part of Freud's personality theory that is the demanding thought of “I want.”
Superego – The moral compass which is our conscience's thoughts of “you can’t have.”
Ego – The reasoning thoughts to balance the demands of id and superego. (Uses defence mechanisms like repression to forget their desires)
Freud suggested that fear is repressed into the unconscious to protect the ego. This is because of unresolved conflict between the id and the superego. OR could be due to the repressed urges of the id that are being denied. Ego uses defense mechanisms to repress the conflict such as displacement. The phobia can be a displaced/redirected fear during an intensely frightening experience (e.g. a physical attack) onto an object.
EXAMPLE STUDY: FREUD – LITTLE HANS (1909)
Oedipus Complex: Part of Freud's phallic stage; a boy has unconscious feelings for his mother and hates his father who he sees as a rival and fears will castrate him.
Little Hans was a five-year-old boy suffering from a phobia of horses, and other symptoms that illustrated the Oedipus complex.
Freud conducted a case study on Little Hans; At the age of three, developed an intense interest in his penis, leading to his mother's threat of castration, resulting in a fear of losing his penis. Hans' father felt this concern was related to horses' large penises. Simultaneously, traumatic events, including the birth of his sister, separation from his mother in the hospital, and witnessing a horse's death, contributed to the emergence of his phobia of horses, particularly white ones. Freud suggested the connection of the horse phobia to his fear of his father, who was symbolized by white horses with black nosebands. The conflict between Hans and his father arose, involving the denial of morning bed access with his parents. By age five, Hans' phobia lessened. Freud noted two fantasies the first involving his mother where he has several children with her and his father was his grandfather, and the second was a plumber had come and replaced his penis with a new larger one, supporting the Oedipus complex dynamics in their relationship.
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Systematic desensitization developed by Joseph Wolpe is a way to reduce undesirable responses to situations. E.g. Managing phobias, because it works on the principles of behavioural psychology and assumes all behaviour is a conditioned response to stimuli in an environment. Therefore, like how in little Albert if phobias can be learned then they can also be unlearned. This is known as counterconditioning: replacing a conditioned response, such as fear, with another response, such as a feeling of calm.
Overall, the theory suggests that a once frightening stimulus should eventually become neutral and provoke no real anxiety.
WOLPE (1958) – "Reciprocal inhibition" is a concept introduced by Wolpe in 1958, suggesting that it's impossible to experience two conflicting emotions at the same time. This idea forms the basis of systematic desensitization, a therapy used to unlearn phobic reactions.
1. Patients learn relaxation techniques, such as progressive muscle relaxation or visualization.
2. Together with the therapist, they create an anxiety hierarchy, ranking fear-inducing situations related to their phobia from least to most distressing.
3. Patients then gradually confront these situations, starting with imagining them (in vitro exposure) and then facing them in real life (in vivo exposure).
4. Throughout the process, patients are encouraged to remain in a calm, relaxed state using their chosen relaxation technique. They progress to the next stage of the hierarchy only when they feel no anxiety related to the current stage.
It's a step-by-step process aimed at replacing fear with relaxation, ultimately helping individuals overcome their phobias.
Systematic desensitization finds more support in animal experiments. For instance, WOLPE (1976) conditioned cats to fear a specific cage using electric shocks. Later, he counter-conditioned them by offering food pellets in cages increasingly resembling the feared one. Initially, the cats showed fear towards similar cages due to generalization, but gradually began accepting food. Eventually, their fear response disappeared, and they entered the original cage without fear, associating it with food instead of shocks. This study is significant as animal experiments offer tighter control, enhancing the validity of findings.
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KEY STUDY NAME: CHAPMAN AND DELAPP (2013)
Nine Session Treatment of BII Phobia with Manualized CBT (Adult Case Study)
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