Motivation and emotion/Book/2019/Phobias

Overview
Case study

Sally has a phobia of bridges (gephyrophobia) which means she is unable to cross very high or long bridges. She is afraid the bridge will collapse and she will fall to her death while crossing. Her fear extends to walking, riding or even driving on a bridge. If she outright has to cross, she will be in a state of absolute terror and panic. She actively avoids crossing any bridge, even if it means missing out on certain social functions and events. Often, even the thought of crossing a bridge makes her anxious. She has had this fear for as long as she can remember and doesn't recall how it began.

Many people have fears; they are commonly induced in the face of danger or threat. Freezing in presence of a snake, feeling dizzy at extreme heights or feeling nervous before a flight, are all considered normal fear responses. However, when the fear or anxiety becomes so intense that its out of proportion to the actual threat and one actively avoids an object or situation, it may be a phobia. Phobias are common and diagnosable anxiety disorder described as an irrational fear of a situation or object. Phobias can be for just about anything and new phobias are constantly emerging in the changing world. So, how do we deal with phobias? There are a number of ways psychologists treat phobias and treatments will often depend on the type and severity. However, its also important to understand how phobias develop and are maintained in the first place (5thed.; DSM–5; American Psychiatric Association (APA), 2013).

Fear, anxiety, and phobia
Both fear and anxiety play a significant part in phobias so it’s important to understand their role. Anxiety is apprehension in anticipation of a perceived threat, whereas fear is the direct emotional response to immediate danger (APA, 2013). The key distinguishing feature being ‘anticipated’ verses ‘immediate’ threats; thus a person worried about the possibility of being attacked on their walk home experiences anxiety, whereas someone held at gunpoint experiences fear. Both can be adaptive; fear triggers the sympathetic nervous system preparing the body for a ‘fight-flight’ reaction. Similarly, anxiety increases our awareness of potential threats and helps us avoid dangerous situations. However, with a phobia, the fear and anxiety is extreme, persistent, disproportionate to the threat, and can produce panic like symptoms (see Table 1). Furthermore, individuals may develop avoidance behaviours to minimise any potential contact with the stimulus, impacting on daily decisions (APA, 2013).

Table 1

Symptoms associated with phobias Adapted from APA (2013).

Types of phobias
The DSM-5 recognises three types of phobias: specific phobia, social phobia (social anxiety disorder) and agoraphobia.

Specific phobias


A specific phobia is an intense fear in response to a specific situation or object. The list is extensive, but the DSM-5 has identified five categories:


 * Animal e.g., dogs, spiders
 * Natural environment e.g., heights, storms
 * Blood /injection /injury e.g., needles, invasive medical procedures
 * Situational e.g., airplanes, elevators
 * Other e.g., situations that lead to vomiting, clowns

(APA, 2013)

A recent cross-national epidemiological study revealed the lifetime prevalence of specific phobias as high as 12.5%, suggesting they are one of the most frequent mental disorders (Wardenaar et al., 2017). They are more common in females, and animal phobias (e.g., arachnophobia, see Figure 1) are the most prevalent subtype (Wardenaar et a., 2017). Additionally, many report having more than one phobia, however only a fraction of sufferers seek treatment (Wardenaar et al., 2017).

Social phobia
Social phobias are an intense fear of social situations where one feels scrutinised by others. Now labelled social anxiety disorder in the DSM-5, it refers to one who is afraid others might think negatively, laugh or ridicule them. They experience anxiety and panic in social situations and often avoid going out altogether, missing school or other important events. Sometimes even anticipating social events will provoke a panic response (APA, 2013). Situations they often fear include meeting new people, attending parties or pubic speaking; the type and number of different situations varies among individuals (Rowa & Antony 2005). Epidemiological studies suggest the lifetime prevalence of social phobia are around 7%, and up-to 80% of individuals do not seek treatment (Grant et al., 2005).

Agoraphobia
Agoraphobia involves fearing and avoiding situations which one cannot escape or escape might be difficult and help unavailable in the event of a panic attack (APA, 2013). Although one may think agoraphobia happens only in closed spacers (e.g., cinemas), many experience symptoms in open spaces such as a parking lot, standing in crowds or even being outside their own home. The thought that escape might not be possible or help won’t reach them in the event of a panic like attack, causes immense fear and results in avoiding such situations all together. In its most severe forms, one might become completely homebound, never leaving their house and relying on others for assistance and services (see Figure 2).

How do they form?


Children experience many fears throughout childhood (see Figure 3). For example, it’s not unusual to hear a child is afraid of the dark or heights. Although most fears disappear spontaneously, in a number of children, they persist (Muris & Merchelback, 1998). Why is it some childhood fears continue into adulthood? There are many factors that increase the risk of developing a phobia. This section will focus on those that have had major influences on treatment outcomes.

Learning theories
From a learning perspective, phobias are a result of associative learning and involve one or more of the following pathways.

Classical conditioning


The classic behavioural perspective is that phobias are acquired through classical conditioning. The basic premise is one may develop a conditioned fear response to a neutral stimulus when its paired with an aversive unconditioned stimulus. Watson and Raynor (1920) attempted to explain the development of phobias in their Little Albert study (see Figure 4). Albert, who was nine months old, was conditioned to fear a white rat which was paired with a loud noise that produced a fear response. Albert initially showed no fear to the white rat. After multiple pairings of the rat and the loud noise, Albert reacted with crying and avoidance behaviours on presentation of the rat alone (Watson & Raynor, 1920). Similar results have since been observed. For example, in a sample of 7-18 year old’s with a fear of needles, almost half recalled experiencing a very unpleasant painful injection (Duff & Brownlee, 1999). Although this theory may explain the fear response, it does not rationalise the avoidance behaviours phobics display. The two-factor learning theory of avoidance may explain this.

Two-factor theory of avoidance learning
The two-factor model proposes fear is learned through classical conditioning and maintained by operant conditioning leading to avoidance behaviours. A key diagnostic criteria for phobias is that objects or situations are actively avoided or endured with intense anxiety (APA, 2013). When fear and anxiety is reduced by avoidance behaviours, the safety seeking act as a reward, reinforcing the behaviour and thus its repeated (Muris & Merchelback, 1998). For example, a child may have a cat phobia as a result of an early childhood cat bite (associating pain from the bite with cats). By avoiding cats, the child’s fear is reduced; the avoidant behaviour is reinforced by the reduction in fear. This theory has great implications for phobia treatment. In the above example, repeatedly exposing the child to cats that don’t bite may help extinguish this fear.

Vicarious learning
Although direct conditioning explains the acquisition of some phobias, it is not without limitations. For example, many adults with phobias cannot recall an incident leading to their fear (Kendler, Myers, & Prescott 2002). Another pathway may be through vicarious learning. As opposed to directly experiencing conditioning, phobias may be acquired by observing fear responses of others (Coelho & Purkis, 2009). A study investigating vicarious learning and fear development in children, paired images of novel animals with scared, happy or neutral facial expressions (Askew & Field, 2007). Results showed children reported increased fear beliefs for animals paired with scared faces. These beliefs persisted for one week when measured explicitly and up to three months when measured indirectly.

Negative information transmission


Negative information is believed to play a role in phobia development. For example, how does one who has never flown in an airplane develop a fear of flying? It's believed the transmission of threatening and negative information may be significant. In the above example, exposure to negative media coverage of flight accidents and incidents might reinforce the fears of those concerned, see Figure 5 (Schindler, Vriends, Margraf, & Stieglitz 2016).

Experimental studies have examined the role of negative information on fear development. Muris and collegues (2003) tested the impact of negative information on 285 children aged 4 to 12 years. The children received either positive or negative information about an unknown dog-like creature called 'the beast’. Results showed that negative information about the creature increased fear levels which remained after one week. Furthermore, those that feared 'the beast’ also became apprehensive of other dogs (Muris, Bodden, Ollendick, & King, 2003).

Cognitive theories
From a cognitive perspective, the way one applies knowledge about a situation or processes information may lead to irrational fears. Negative beliefs, attention to threatening information, self-efficacy and perceptions of control are thought to be contributing factors not only to the development of phobias, but also its maintenance.

Self-efficacy theory
People with low self-efficacy and perceived lack of control over their environment, may have a higher risk of developing anxiety disorders. Bandura’s self-efficacy theory suggests people may become fearful of aversive events if they feel incapable or inefficacious in dealing with potential threats; phobic behaviour may be caused and maintained by these beliefs (Bandura, 1983). If one feels they have control over an unpleasant event, even one that could lead to injury, they do not fear it (Bandura, 1983). Perceived control and self-efficacy have been vastly tested in relation to fear and phobia. Johnston and Page (2004) tested the impact of distraction on spider phobics undergoing in vivo exposure therapy. They found participants who were distracted had better outcomes than those who focused on the stimulus. Being distracted led to greater reductions in subjective fear, and increases in self-efficacy and perceived control. Furthermore, throughout the task, higher self-efficacy was predictive of superior performance on phobia related tasks (Johnston & Page, 2004).

Attention to threat
People with phobias may have an increased focused on danger and threatening information in their environment. In general, attention biases can be adaptive and aid detection of threatening stimuli and danger. However, those with a phobia often focus on non-dangerous stimuli. To test attention bias, researchers developed measures like the Stroop test, in which participants are asked to quickly name the colour of words; delays indicating attention to the meaning of the word (Maidenberg, Chen, Craske, Bohn, & Bystritsky 1996). In a study testing attentional bias in social phobia, researchers found participants with social phobia took longer to respond to social-threat words, indicating attentional biases to socially applicable information (Maidenberg et al., 1996). Although, attentional biases may not explain the developmental origins of phobias, they do imply that once developed, phobics may focus on threatening information, maintaining and strengthening the phobia. Consequently, attentional focus training has been integrated into cognitive therapy treatments (Rowa, & Antony, 2005).

Neurobiological factors


Fear circuits and mechanisms have been identified in both innate and conditioned fear responses; dysfunctions in these mechanism may result in the development of a phobia (Garcia, 2017). There is much research indicating the involvement of the amygdala in fear. Figure 6 shows the amygdala highlighted in red; it's a small almond shaped structure, believed to be involved in assigning emotional significance to an object. In response to fear, studies have shown increased activity in the amygdala; in phobic patients activation is significantly higher (Münsterkötter, 2015). Additionally, studies using electrophysiological recordings, support the role of the amygdala in fear associations (encoding and storing), indicating its crucial role in fear conditioning and learning (Maren, 2001).

The insula and hippocampus are believed to be involved in expectations of aversive stimuli. Simmons, Matthews, Stein and Paulus (2004) observed activation of these regions during anticipation of emotional aversive images (spiders and snakes). Research has also illustrated the function of the prefrontal cortex in emotional regulation, with evidence to suggest involvement in extinguishing fears (Maren, 2001). Additionally, abnormal functioning in neurotransmitter activity may contribute to the development of anxiety disorders such as phobias (Kaur & Sing, 2017). Table 3 presents a brief summary of some neurotransmitter functions, which have been employed in pharmacological strategies treating anxiety.

Table 3

The role of neurotransmitters in anxiety

Adapted from Kaur and Sing, (2017)

Treatment options
In the treatment of phobias there are a number of options available. A meta-analysis investigating treatment efficacy for phobias, found those treated were 84% better off than untreated participants (Wolitzky-Taylor, Horowitz, Powers, & Telch, 2008). Despite availability of treatments, many suffering are hesitant to seek help.

Cognitive behavioural therapy


Cognitive behavioural therapy (CBT) is commonly used to treat phobias. It integrates cognitive therapy (e.g., education about the nature and cause of symptoms or restructuring maladaptive cognitions) alongside behavioural techniques such as breathing training (see Figure 7). Clinicians often pair an exposure method with CBT so patients learn to apply the techniques through gradual exposure. CBT also involves a relapse prevention element, where patients are informed the likeliness of a relapse and to reapply behavioural coping skills (Wolitzky-Taylor et al., 2008). A meta-analysis involving over 30 randomised trials, reported CBT as the most effective psychological treatment for social phobia, offering better relapse protection than medication (Canton, Scott, & Glue, 2012).

Exposure based therapies
Facing ones fear, although a daunting thought for some, can be effective in treating phobias. Exposure therapies involve confronting the feared stimulus to re-condition and associate it with positive experiences (Muris & Merchelback, 1998). Used alongside modelling, positive information, and cognitive interventions, one can re-learn while simultaneously breaking avoidant behaviours. A meta-analysis of 33 clinical trials conducted over three decades on treatment approaches for specific phobias, found exposure therapies the most potent and durable. In vivo contact, imagined therapy and virtual reality all outperformed over alternative psychotherapeutic approaches (Wolitzky-Taylor et al., 2008).

Systematic desensitisation
Systematic desensitisation involves deep muscle relaxation, development of a goal hierarchy and gradual exposure of the feared stimulus (Wolitzky-Taylor et al., 2008). Exposure begins with the lease anxiety provoking (e.g., hearing the word spider) and gradually progresses to the most fear provoking (e.g., having a spider in the room). As with most treatments, the number of session will usually depend on the type and severity of the phobia. Although it can be a successful method, evidence suggests exposure treatments still work without the addition of deep relaxation (Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998).

In vivo exposure
In vivo exposure involves direct exposure to a feared stimulus and is commonly used to treat specific phobias (Muris & Merchelback, 1998). Its done in a gradual manner, starting from the lease to the most anxiety provoking exposure. This can take place over a number of sessions or one prolonged single session, and consent is given at each stage (Wolitzky-Taylor et al., 2008). Group exposure therapy can also be effective. Öst (1996) conducted a study comparing treatment outcomes of small and large groups of patients with spider phobia. Results revealed both groups significantly improved on all measures (behavioural, physiological and self-report) after just one three hour long session of exposure and modelling; these results were maintained or improved in the one year follow up (Öst, 1996). However, for some phobias direct contact may not be possible; advances in technology have provided a solution.

Virtual reality exposure
Virtual reality (VR) involves exposing the patient to computer generated virtual environments containing the feared stimulus, as an alternative to taking them into real environments or directly exposing them to objects (see Figure 8). VR integrates visual displays, body tracking devices and real time computer graphics, immersing the patient into a virtual world controlled by the therapist. VR has been effective in treating specific phobias. Using relatively low-cost hardware and software, Emmelkamp, Bruynzeel, Drost, van Der Mast, and Emmelkamp (2001) found VR to be as effective as in vivo exposure in treating acrophobia (fear of heights). Improvements were seen across anxiety, avoidance, and attitudes. Furthermore, VR seems to be the favourable treatment option for patients when compared with in vivo, with fewer refusal rates (Garcia-Palacios, Botella, Hoffman & Fabregat, 2007).

Augmented reality
A more recent adaption to exposure therapy is augmented reality (AR). It combines VR (computer graphics) with one’s own space in real time to form images that are a blend of the real world and virtual elements. A study investigating treatment outcomes for AR verses in vivo exposures, found AR to be as effective in the treatment of small animal phobias (Botella et al., 2016). Furthermore, participants considered the AR experience to be less aversive than direct exposure. For those fearful of facing their phobia, computer simulated realities may be a tolerable option.

Conclusion
The purpose of this chapter was to answer the question - What are phobias are and how can they be dealt with? To extend on this, how one may develop and maintain their phobia was provided, to give an understanding of the underlying mechanisms of psychological treatments. In summary, phobias are a common anxiety disorder marked by extreme fears and avoidance behaviours. They differ from a normal fear response as phobia fear is disproportionate, irrational, persistent, and one takes extreme measures to avoid the feared stimulus. Often, people suffering from a phobia will experience physical and psychological symptoms when faced with their fear. However, cognitive and behavioural measures have been developed to provide one with the information needed to understand and overcome these symptoms. The list of phobias is extensive and the DSM-5 has organised phobias into categories and subtypes to assist with diagnosis. Theories around learning and cognition attempt to explain how one might have developed and maintained their phobia. Accordingly, many treatments have been designed around these theories.

Although not everyone with a phobia will seek treatment, those suffering should be aware that there are multiple treatment options available and outcomes are promising. Many treatments include a form of exposure to the feared object or situation; understandably, this might be a frightening thought for some. However, the steps are gradual and alongside appropriate information about the object and ones symptoms, research has shown it to be a beneficial tool in dealing with phobias. Avoidance behaviours practiced by phobics seem to provide some relief from fear and anxiety, however, theories around learning explain that continuous avoidance may actually strengthen the phobia. Exposure therapy attempts to weaken this association and provide avenues for new learning about the object of ones fear. The hope is that one who reads this information, gains insight into phobias and how they can be treated.