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Anxiety & related disorders > Case 2: Fear! > Flashcards

Case 2: Fear! Flashcards

1
Q

What are specific phobias?

A
  • significant fear about a specific object or situation that doesn’t pose a threat
  • Full intensity of fear is experienced upon actual exposure to the phobic trigger, but specific phobias can also be characterised by similar intense reaction even in anticipation of coming into contact with the feared object or situation (representation).
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2
Q

What is the DSM 5 for specific phobias?

A
  1. Marked fear/anxiety about specific object/situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
  2. Phobic object/situation almost always provokes immediate fear/anxiety.
  3. Fear/anxiety = out of proportion to actual danger posed by specific object/situation & to the sociocultural context.
  4. Phobic object/situation is actively avoided/endured with intense fear or anxiety.
  5. Fear, anxiety, avoidance causes significant distress/impairment in social, occupational, or other areas of functioning.
  6. Fear, anxiety, avoidance is persistent, lasting for 6 months or more.
  7. Disturbance is not better explained by symptoms of another mental disorder, including:
  • fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms;
  • objects or situations related to obsessions;
  • reminders of traumatic events;
  • separation from home or attachment figures; or social situations.
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3
Q

Whatr are the subtypes of phobia specified by DSM?

A
  • Animals
  • Natural environment
  • Blood-injectio-injury (BII)
  • Situational
  • Other (fear cued by other stimuli, like toys, clowns, choking or vomiting)
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4
Q

Explain the subtype animal phobia

A
  • (fear cued by spiders, snake, rates, mice, dogs, etc.)
  • Characterised by a sympathetically dominated autonomic physiological fear response pattern accompanied by the central concern of freaking out and losing control
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5
Q

Explain natural environment phobia

A
  • (fear cued by heights, thunderstorms, being on or in the water)
  • Characterised by symptom reports of dizziness (in the case of fear of heights) and strong avoidance dispositions often accompanied by central concerns about the potential danger of the situation ( tornado might hit house, lightning might set fire to house).
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6
Q

Explain natural environment phobia

A
  • (fear cued by heights, thunderstorms, being on or in the water)
  • Characterised by symptom reports of dizziness (in the case of fear of heights) and strong avoidance dispositions often accompanied by central concerns about the potential danger of the situation ( tornado might hit house, lightning might set fire to house).
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7
Q

Explain BII phobia

A
  • (BII, e.g. needles, blood draws, open wounds);
  • Fear of blood
  • Fear of medical care in general
  • Fear of injections and transfusions
  • Fear of injury
  • Marked by a instant increase in heart rate and blood pressure, followed by a vagally mediated bradycardia (slower HR) and hypotension (low BP) that can = to passing out, accompanied by the concern of fainting or feeling nausea
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8
Q

Explain situational phobia

A
  • (e.g. driving, flying, enclosed spaces)
  • Characterised by strong cognitive symptoms and concerns such as losing control, going crazy, or suffocating, accompanied by a very strong urge to escape, e.g. from the enclosed place
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9
Q

How does each suybtype vary?

A
  • age of onset
  • gender distribution
  • familial concordance
  • patterns of phobic responding
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10
Q

What is the epidemiology of specific phobias?

A

*most common specific phobias include fear of animals, fear of heights, and fear of thunderstorms.
* Specific phobias are more common among adolescents and less common among older adult populations.
* Adult diagnosis associated with childhood and/or adolescence diagnosis of specific phobia.
* Rates of specific phobia are also higher among females compared to males.

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11
Q

What is the natural course of specific phobia?

A
  • Many phobias begin in childhood or adolescence → early onset.
  • Animal & BII phobias tend to start earlier than natural environment & situational phobias.
  • Specific phobia patients know what they are afraid of & ‘how’ they are afraid of it → distinguishes specific phobia from other anxiety disorders and aversions.
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12
Q

Explain impairment in specific phobias

A
  • Increase in # of specific fears = increase impairment
  • greater interference in daily & social functioning
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13
Q

What 3 components does the process of anxiety have?

A
  • Motoric escape & avoidance;
  • Physiologic activation of sympathetic branch of the autonomic nervous system
  • Cognitive appraisals of threat & harm.
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14
Q

What is the comorbidity/co-occurence of specific phobia?

A

Specific phobia likely to be ‘secondary’ to other anxiety disorders (or mood disorders)

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15
Q

What is the aetiology of specific phobias?

A
  • Genetic risk factors → genetic vulnerability.
  • Environmental risk factors → parent control, overprotection, parental meddling.
  • Cognitive perspectives
  • associative accounts
  • biological and evolutionary accounts
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16
Q

Explain environmental risk factors for specific phobias (part of aetiology)

A
  • e.g. parental control and overprotection of anxious children = increased risk of developing anxiety disorder
  • parental meddling facilitates avoidant behaviours among anxious children
  • informational learning
  • Vicarious learning
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17
Q

Explain cognitive perspectives as the aetiology of specific phobias

A
  1. maladaptive cognitions/schemas = vulnerabilities for specific fears & phobias.
  2. Some cognitive vulnerabilities are thought to be responsible for transition specific fears –> specific phobias.
  3. Cognitive vulnerabilities include:
    Appraisals of feared object as: dangerous, disgusting, uncontrollable, & unpredictable DDUU
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18
Q

**Explain associative accounts as the aetiology of specific phobias

A
  • fear of a previously neutral stimulus can be established via classical conditioning.

Mowrer’s two factor model of fear and anxiety aetiology and maintenance
* Mowrer proposed: fears are established via CS-UCS pairings.
* Focused on maintenance & propagation of fear responding via pathological avoidance.
* Mowrer stated that phobic stimuli (CS) elicit fear (CR), which motivates escape behaviours (R).
* Also imagery of symbolic representation of phobic stimuli (CS) elicit anxiety (CR), which motivates avoidance (R).

Rachman (1977) → vicarious pathway: fear can be learned by observing others or via receiving threatening (fear-relevant) information.
* E.g. after observing their mother react negatively to a novel toy (e.g., react with facial displays of disgust and fear or outright avoidance of the toy), toddlers will respond with greater fear and avoidance when presented with said toy

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19
Q

Explain biological and evolutionary accounts as the aetiology of specific phobias

A
  • Evolutionary adaptive to possess some fear of most common phobic stimuli (e.g snakes, heights, blood).
  • Less common (flowers) & more elaborate (driving) specific phobias - which develop much later in life than simple fears - are less evolutionary adaptive & thought to arise as consequence of learning
  • Biologically prepared fears easier to establish, more powerful once established & more resistant to extinction.
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20
Q

What is the fear module of fear and learning?

A

Independent neural & behavioural system that developed through evolutionary selection & serves purpose of adapting to & preventing historically common dangerous situations.

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21
Q

What primary characteristics does the fear module of fear and learning possess?

A
  1. Selectivity
  2. Automaticity
  3. Encapsulation or resistance
  4. Specific neural circuitry
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22
Q

What primary characteristics does the fear module of fear and learning possess?

A
  1. Selectivity
  2. Automaticity
  3. Encapsulation or resistance to concious cognitive influences
  4. Specific neural circuitry
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23
Q

What are the pathways to fear?

A
  1. Classical conditioning (pavlov)
  2. Vicarious learning
  3. Information learning
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24
Q

What are examples of unconditioned stimuli in anxiety?

A
  • Falling down from a bridge (fear of heights)
  • Being attacked with a knife (GAD)
  • An armed burglar entering your house (OCD, GAD)
  • Getting filthy dirt in your mouth (OCD)
  • Having a heart attack (PD)
  • Not being able to breath (PD)
  • Being humiliated by a teacher in front of your classmates (SAD)
  • Getting hit by a car (GAD)
  • Having a little animal that can bite you running down your clothes (spider phobia)
  • Seeing your child die (GAD)
  • Seeing a loved one in great emotional pain (GAD)
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25
Q

What are examples of unconditioned response in anxiety?

A
  • Sympathetic activation (release of adrenaline)
  • Parasympathetic activation decreases
  • atypical anxiety/fear reactions
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26
Q

What are examples of sympathetic activation of UCR?

A
  • Blood pressure increases
  • Heart rate increases
  • Respiration increases
  • Sweating increases
  • Increase of blood in muscles
  • Tense muscle: trembling of hands, other parts
  • Tingling of hand and feet
  • Pupils enlarge (see more light)
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27
Q

What are examples of parasympathetic activation decreasing of UCR?

A
  • Contraction of bladder and intestinal (urge to go to the toilet)
  • Digestion stops: dry mouth and throat
  • Feel sick
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28
Q

What are examples of atypical anxiety/fear reactions of UCR?

A
  • Crying (loved one dying, emotional pain)
  • Drop in blood pressure (specific for blood phobia)
  • Blushing (specific for social anxiety disorder)
29
Q

Explain vicarious learning as a pathway to fear

A
  • Learning through observing others fear response.
  • Experiencing a stimulus and someone else’s reaction to it
  • Observed reaction to the CS acts as a US (that is, someone else’s distress is itself anxiety-evoking)
  • Also impacted by gender e.g. if mum scared of bugs, often daughter also scared.
30
Q

Explain informatio learning as a pathway to fear

A
  • Verbally telling you about the phobia
  • negative information/description about certain things and making associations (e.g. describe the stimuli as disgusting or scary). - a lot of childhood fears arise
31
Q

Would the same therapy (e.g. exposure) be effective for both GAD and specific phobias?

A
  • coping strategies are the same
  • The cues for a specific phobia are different compared to generalised anxiety disorder.
32
Q

What are the individual treatment techniques for BII?

A
  • Exposure (E)
  • Applied relaxation (AR)
  • Applied tension (AT)
  • Tension only (T)
33
Q

Explain exposure as an individual treatment technique for BII phobias

A

Exposure to the feared object or situation would be a natural choice for the treatment of BII phobia. In vivo exposure → patients are confronted with an individualised hierarchy of feared situations.

34
Q

Explain applied relaxation as an individual treatment technique for BII phobias

A

progressive relaxation technique, with repeated sequences of brief tensing of various skeletal muscle groups followed by release of tension (not relaxation).

35
Q

Explain applied tension as an individual treatment technique for BII phobias

A
  • combines a muscle tension technique with in vivo exposure.
  • addressed issue of preventing a fainting response by raising BP, venous return, & cerebral blood flow = reducing chance of losing consciousness.
36
Q

Explain tension as an individual treatment technique for BII phobias

A
  • Can also do without the AT but because these people are afraid of fainting, the AT can help because fear of fainting is another fear on top of another fear.
37
Q

What are the general treamtnets for specific phobia?

A
  • exposure therapy
  • virtual reality exposure therapy
  • cognitive theray
  • pharmacotherapy
38
Q

**Explain exposure based treatments

A
  • Systematic desentization
  • Conditioned inhibition
39
Q

What are the 3 phases of in-vivo exposure therapy?

A
  1. Instruction phase
  2. direct in vivo exposure
  3. maintenance of treatment results
40
Q

Explain the instruction phase of in vivo exposure therapy

A
  • Patients given plausible model for their phobia
  • Therapy is teamwork (patient and therapist)
  • Explained that they probably always avoided the situation or left at the peak of the fear which strengthened it.
  • Explanation on mechanisms of change (stay in feared situation) and it is important to stay in the situation as long as possible (next 3 points):
  • Fear will not increase to inestimable point
  • Fear will ultimately fade away
  • Explore patient’s central concerns so that they can be addressed and treated using cognitive techniques during direct exposure therapy
41
Q

Explain the direct in-vivo exposure phase of in vivo exposure therapy

A
  • Introduction of exercise, modelling it and patient practice it
  • patient should approach the feared object as far as possible and stay in this position until the fear completely disappears or is reduced by at least 50%
42
Q

Explain the maintenace of treatment results phase of in vivo exposure therapy

A
  • practising at home using self-exposure techniques;
  • what to do in case of a setback
43
Q

Explain virtual reality exposure therapy (VRET)

A
  • Visual displays of moving objects, sensory inputs, body-tracking pieces
  • Especially useful in situations where environment for exposure is difficult to realise (flight and height phobias) natural environments phobia.
44
Q

Explain cognitive therapy

A

Cognitive therapies are effective for treating claustrophobia, but are less effective than exposure therapy for treatment of animal, dental, and flying phobia.

45
Q

Explain pharmacotherapy

A
  • Only if patients have not responded to psychological approaches, a SSRI or benzodiazepine could be potential treatment alternatives.
  • medication provides little to no benefit in the treatment of specific phobias → don’t work well cause it numbs our brain and inhibits learning which makes it harder to ‘learn’ new associations and treat anxiety.
  • Exposure techniques should be used as “first-line treatment”.
  • Want to make new associations (if we take something that numbs our brain and inhibits learning we are avoiding and not making new associations)
    selective serotonin reuptake inhibitor or benzodiazepines
46
Q

Explain the efficacy of exposure-based therapies

A
  • Specific phobias are responsive to exposure-based therapies & therefore considered the treatment of choice for this disorder;
  • Exposure-based therapies = better outcomes at post-treatment
  • Exposure-based therapies are highly effective & produce stable improvement in self-reported fear and behavioural avoidance
47
Q

What is the central mechanism of change during exposure therapy

A

Central mechanism of change during exposure therapy would be counterconditioning, i.e., if a response antagonistic to fear (e.g., relaxation) is initiated during the presence of a fear-eliciting cue resulting in an inhibition of the fear response, this cue will become a conditioned inhibitor and will engage counterconditioning.

48
Q

What are the mechanisms. ofchange

A
  • Habituation
  • Extinction
49
Q

What is habituation?

A

decrease in response to a stimulus after repeated presentations

50
Q

How can the term extinction be used in more than one sense?

A
  1. to describe the experimental procedure during which a conditioned stimulus (CS) that has previously been paired with an unconditioned stimulus (UCS) is now presented without the unconditioned stimulus
  2. to describe the result of the effect, the reduction of the previously conditioned fear response, that can be observed even after several days (long-term extinction
  3. to describe the associative neuronal learning process that underlies the reduction of the fear response.
51
Q

What is extinction?

A

fading & disappearance of behavior previously learned by association with another event

see image

52
Q

What are the phases of extinction?

A
  1. acquisition
  2. consolidation of the extinction memory
  3. retrieval of the extinction memory
53
Q

Explain the phases of extinction

see image

A
  • Phase 1: During the first phase the individual learns that the fear cue is no longer followed by the aversive consequence (“I do not scream and run out of the room when I see the spider”; “I will not suffocate in the elevator”) → causes the fear response to reduce (see Figure 45.3).
  • Phase 2: the learning experience is consolidated and the inhibitory associations are reinforced.
  • In the case of successful long-term extinction, extinction memory is recalled in other contexts.
  • Under critical circumstances (e.g., if critical life events increase), recall of extinction memory can be blocked.
54
Q

What are extinction neurons?

A

fire during extinction training (in the amygdala).

55
Q

When can increased activation of the amydala be observed?

A
  • during the beginning of extinction learning.
  • With increasing duration of extinction, activation of amygdala decreases.
  • recall of extinction memory is associated with activation of prefrontal cortex.
56
Q

Explain disgust sensitivity with regards. to BII and spider phobias

A
  • Disgust sensitivity is a robust predictor of spider fears and BII fears and the predictive power of disgust sensitivity remains significant when controlling for trait anxiety and/or negative affect.
  • State subjective disgust predicts avoidance of spider and injection/injury stimuli above and beyond state fear and anxiety.
  • Disgust = primary motivator & vulnerability factor underlying the maintenance & aetiology of phobic avoidance and negative reactions to spiders, blood, injections, and injuries
  • the higher the disgust sensitivity, the intenser the phobia
57
Q

Why do some poeple faint if they are confronted with their phobias?

A

Fainting response (emotional fainting) is characterised as a vasovagal syncope and has been described as a two-phase, or biphasic (also called diphasic) response to BII stimuli.

  • Initial phase involves an increase in heart rate and blood pressure as is typical of the fight-flight component of an anxiety response
  • 2nd phase is characterised by bradycardia (a sharp drop in heart rate) & hypotension (low blood pressure) leading to reduced cerebral blood flow and ultimately fainting.
  • Fainting in response to BII stimuli can lead to avoidance → avoidance of situations related to blood, injury, and injections poses a serious threat to an individual’s well being as it can lead to the neglect of medical care and life-saving treatments
58
Q

Why exposure when you have AT for BII patients?

A

For BII, exposure therapy is still important, however as soon as they recognize phase 1 of the diphasic response to the fear, they can apply the applied tension technique.

  • exposure therapy is just as effective as without, but the applied tension gives the patient a sense of control.
  • applied tension could also help with getting therapy.
59
Q

What are the differences between agoraphobia and specific stiuation based phobias?

A
  • agoraphobia: fear of not being able to escape from fearful situations
  • Fear and avoidance have to be reported for two or more situations to meet the criteria for the diagnosis of agoraphobia
  • agoraphobia → mainly focussed on the behaviour (will I be able to escape, will I be able to get help) (fear of the fear)
  • Specific phobia situational type → fear for the harm of the thing they fear (afraid of dying in an elevator (claustrophobia)
60
Q

What are the 11 principles of the learning theory?

A
  1. Equipotentiality
  2. Extinction
61
Q

What is equipotentiality?

A

the observation that any predictor should be able to enter into an association with any outcome → a phobia of anything can develop provided that it is at some point experienced alongside trauma.

62
Q

What are criticisms of learning theory?

A
  • ** Retrospective recall** → patients with specific phobia have no memory of associative learning event(s) → there are no reliable differences between phobic and non-phobic groups.
  • Conditioning has been seen by many as a poor explanation of how fears develop: partly because research on conditioning has become less mainstream and models of learning have become increasingly more complex.
63
Q

What are criticisms of conditioning as an explanation of phobias?

A
  • Some phobics cannot remember an aversive conditioning experience at the onset of their phobia (aversive conditioning episode).
  • Not all people experiencing fear or trauma in a given situation go on to develop a phobia.
  • Uneven distribution of fears
  • Incubation of fear
  • Indirect pathways to fear
64
Q

Explain the aversive conditioning episode as a criticism of conditioning for explanation of phobias

A
  • Many phobics, such as snake and spider phobics and height and water phobics, do not remember an aversive conditioning episode. However, others have shown that dental and dog phobics respectively can remember traumatic events. Also, for a particular feared stimulus some individuals do remember an associated traumatic event while others have no such memory.
  • Although much of the evidence suggesting that phobics do not report traumatic memories is retrospective and, therefore, prone to memory biases, these findings are nevertheless problematic for simple conditioning explanations, which rely on a traumatic learning episode.
65
Q

Explain the development of phobias as a criticism of conditioning for explanation of phobias

A
  • Not all people experiencing fear or trauma in a given situation go on to develop a phobia.
  • Memory profiles of individuals with the same fears differ. However, there is specific evidence that not all people who have traumatic incidents while at the dentist or flying, or who experience severe thunderstorms go on to develop phobias. A simple conditioning account of fear acquisition simply cannot explain why similar experiences produce phobias in some, but not others.
66
Q

Explain the uneven distribution of fears as a criticism of conditioning for explanation of phobias

A
  • Law of equipotentiality suggests that all stimuli are equally likely to enter into an association with an aversive consequence. However fears and phobias are not equally distributed → there are common fears and phobias (e.g. spiders, snakes, dogs) and non-common phobias (e.g. knives, hammers) → even though the latter group seems to have a high likelihood of being associated with pain and trauma.
  • Some people also acquire conditioned fear responses more rapidly to some stimuli (fear-relevant stimuli) such as snakes and spiders, than to ‘fear- irrelevant’ stimuli such as rabbits and flowers.
67
Q

Explain the incubation of fear as a criticism of conditioning for explanation of phobias

A
  • Although conditioning theory would predict that fear should decrease over successive non-reinforced presentations of the CS, the opposite is often true.
  • E.g spider phobic subsequently comes into contact with spiders, each spider is unlikely to be paired with a traumatic event, so fear should decrease (extinction), but instead the phobic becomes more fearful of spiders.
68
Q

Explain the indirect pathways to fear as a criticism of conditioning for explanation of phobias

A

Fears can be acquired through verbal information and vicarious learning (observing others). This observation implies that conditioning alone is not an adequate explanation of how phobias develop.

69
Q

What did Menzies & Clarke propose with regards to the biological & evolutionary accounts as the aetiology of specific phobias

A
  • Menzies and Clarke (1995) proposed that many specific fears are inborn & phobias are largely a consequence of failed safety learning.
  • Nonassociative model relies on environmental & individual differences that help/hinder learning.

Anxiety & related disorders (5 decks)

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