Specific Phobia

OVERVIEW• Anxiety• Fear v/s Anxiety• Specific phobia• ICD-10 v/s DSM-5• Epidemiology• Differential diagnosis• Comorbidity• Assessment• Aetiology• Management

ANXIETY

• State of apprehension or worry arising out of anticipation of danger

• Normal phenomenon- life saving qualities to prevent threat

• Pathological when it causes significant impairment in functioning.

(Sadock et. al, 2015)

Two Components of Anxiety Experience

Physiological SymptomsMotorTremorsRestlessness

Autonomic PalpitationsHyperventilationDry mouthSweatingFrequent urination

Psychological SymptomsCognitive Concentration, Hyper-arousal

Perceptual Meaning of events-Select certain

things in environment & overlook others in an effort to prove that they are justified in considering the situation frightening

Affective Apprehension, Irritability

Fear

• Emotional response to real or perceived unavoidable threat

• Apprehension in response to external danger

• Emotional response- suddenness of fear

• Emotion caused by a rapidly approaching car as a person crosses the street

Anxiety

• Anticipation (expectancy) of future threat

• Apprehension in response to danger internally perceived

• Emotional response- insidiousness of anxiety

• Discomfort a person may experience when meeting new persons in a strange setting

v/s

PHOBIA

Recurring, excessive and unreasonable psychological or autonomic symptoms of anxiety in presence of a specific feared object or situation leading to avoidance.

(Semple et. al, 2005)

SPECIFIC PHOBIA

• Strong, persisting irrational fear of an object or situation.

• Stimulus is well-defined (in contrast to agoraphobia/ social phobia where it is generalised)

• Differs from developmentally normative fear or anxiety by being excessive or persisting beyond developmentally appropriate periods.

ICD-10

• F40 Phobic anxiety disorders F40.2 Specific (isolated) phobias

• Anxiety restricted to highly specific situations or objects like animals, thunder, heights, disease

• Autonomic symptoms as primary manifestation

• Phobic situation is actively avoided

DSM-5• Anxiety disorders 300.29 Specific phobia• Marked fear or anxiety about a

specific object or situation• Actively avoided• Fear is out of proportion to the

actual danger• 6 months or more• significant distress in important

areas of functioning

DSM specifiers:• Animal (spiders, insects, dogs)• Natural environment (heights, storms, water)• Blood-injection-injury:– fear of blood– Fear of injections and transfusions– Fear of other medical care– Fear of injury

• Situational (airplanes, elevators, enclosed places)• Other (situations leading to choking/vomiting; in children: loud sounds

or costumed characters).

When diagnosing in children:• Express fear by crying, tantrums, freezing or clinging• Assess whether it is typical for the child's particular developmental

stage

(American Psychiatric Association, 2013)

Epidemiology

• Lifetime prevalence: 6-23%• Females more frequently

affected than males• Usually develops in early

childhood• Can develop after traumatic

event• Chronic course with restriction

of ADL• Can spontaneously remit

Differential diagnosis

• Agoraphobia• Social phobia• OCD• Hypochondriasis• Delusional disorder• PTSD

Comorbidity• Panic attack• Depression• Substance-related

disorders

Agoraphobia

DSM-5

Marked fear/anxiety about two (or more) of the following five situations:

1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).

2. Being in open spaces (e.g., parking lots, marketplaces, bridges).

3. Being in enclosed places (e.g., shops, theaters, cinemas).

4. Standing in line or being in a crowd.5. Being outside of the home alone.

ICD-10

Anxiety must be restricted to (or occur mainly in) at least two of the following situations:

1. Crowds2. public places3. travelling away from

home 4. travelling alone

Assessment

• Fear Survey Schedule (FSS-III)• Fear Questionnaire• Acrophobia Questionnaire• Mutilation Questionnaire• Medical Fear Survey• Dental Anxiety Inventory

(Kanwal et. al, 2008)

AETIOLOGYBiological Perspective:

• 64% patients with blood & injection phobia have at least one first degree relative with same phobia

• Increased norepinephrine- hyperarousal• Clinical studies of serotonin function in anxiety disorders have shown mixed

results.• Reduced levels of GABA

(Sadock et. al, 2015)

Psychoanalytic Perspective:

• Anxiety as a result of psychic conflict between unconscious sexual or aggressive wishes and corresponding threats from the superego

• Focus on content of phobia• Phobic object as a symbol of important unconscious

fear• Little Hans

(Sadock et. al, 2015)

Behavioural Perspective:

• Watson- Little Albert• Observational learning

Cognitive Perspective:

• Maladaptive cognitions • Cognitive distortions (exaggeration)• Engage in negative self-statements

(Ginsburg & Silverman, 1998)

Two Factor Theory (Mowrer, 1960)

• Fear acquired by classical conditioning and maintained by operant conditioning

Classical conditioning• Biting of dog(UCS) and pain (UCR) are associated. • So, dog (CS) invokes fear (CR)

• Link b/w CS and UCS decays overtime and eventually ceases to elicit CR.

• Many times this process is blocked because the person learns that fear can be minimized by avoiding or escaping from CS (dog).

• In other words, avoidance or escape is operant behaviour which is negatively reinforced that prevents classically conditioned fear from being unlearned.

• Problem in model- fear in absence of conditioning or no fear in spite of fear-evoking situations

Pathways to Fear Acquisition (Rachman, 1977)

1) Direct conditioning- fear acquisition through classical conditioning

2) Modelling- vicarious acquisition due to observational learning

3) Informational and instructional transmission (fear invoking information/ misinformation)

Latent Inhibition

Aversive conditioning experiences less likely to produce phobias when person has h/o fearless contact with stimulus

Preparedness Theory (Seligman, 1970)

• We are biologically prepared to acquire fears of some stimuli.

• Evolution has predisposed organisms to learn those associations easily that facilitate species survival.

• Some stimuli more likely to be fear evoking than others (snakes, spiders, height).

Anxiety Sensitivity (Reiss, 1980)

• Fear of anxiety-related sensations (fear of palpitations, dizziness & tremulousness) which arises from beliefs that these sensations have aversive somatic, psychological or social consequences.

• AS is one of the 3 fundamental fears including illness/injury sensitivity & fear of negative evaluation.

• Fundamental fears exacerbate other (common) fears such as fears of animals, social situations, blood-illness-injury stimuli and agoraphobia.

• Fundamental fears have 2 features that distinguish them from common fears:

1) They are fears of stimuli that are inherently noxious for most people.

2) Common fears can be logically reduced to them.

• Fear of flying may be due to fear of plane crashing (illness/injury sensitivity), fear of anxiety evoked by turbulence (AS) & fear of embarrassing oneself by becoming airsick (fear of negative evaluation).

• Thus, a common fear (of flying) may be logically reduced to one or more fundamental fears.

(Blaney & Millon, 2008)

Meta-cognitive Model (Wells and Matthews, 1994)

• Monitors, controls and assesses the products and process of awareness.

• Anxiety and sadness- internal signals, threat to well-being.

• Normally of limited duration because the person engages coping strategies to reduce threat and control cognition.

• Psychological disorder results from maintenance of emotional responses.

• Maintained because of individual’s thinking style and strategies.

• This style is called Cognitive Attentional Syndrome (CAS)

-Consists of worry/rumination, threat monitoring-Unhelpful thought control strategies (avoidance)-Prevents adaptive learning

• CAS is the result of faulty meta-cognitive beliefs which control and interpret thinking and feeling states.

• CAS prolongs and intensifies negative emotional experience.

ManagementBehaviour therapy• Systematic desensitization• Flooding• Modelling

Cognitive behaviour therapy To recognize fear as unreasonable, to break the anxiety pattern

Psychodynamic therapyTo uncover repressed conflicts underlying extreme fear

PharmacotherapyBenzodiazepines to reduce anticipatory anxiety

REFERENCES

• Ahuja, N. (2011). A Short Textbook of Psychiatry (7th ed.). Jaypee Publishers.

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA, American Psychiatric Association.

• Blaney, P. H., & Millon, T. (2008). Oxford textbook of psychopathology. Oxford University Press.

• Ginsburg, G. S. & Silverman, W. K. (1998). Specific Phobias. In Bellack, A. S. and Hersen, M. (Eds.). Comprehensive Clinical Psychology. Amsterdam, Netherlands: Elsevier Science.

• Kanwal, K., Rajender, G. & Grover N. (2008). Management of specific phobias. Journal of Mental Health & Human Behavior. 13(2):17-26.

• Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia: Wolters Kluwer.

• Semple, D., Smyth R., Burns, J., Darjee, R. & McIntosh, A. (2005). Oxford Handbook of Psychiatry (1st ed.). Oxford University Press.

• World Health Organization. (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organisation.