Mental Disorders >> Phobic Disorder

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Anxiety Disorders
Phobic Disorder
M. S. Ahluwalia

Psychopathology

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Psychopathology >> Clinical Features of Anxiety Disorders - Phobic Disorder >> Contents
Contents
1. Introduction to Anxiety Disorders
2. Phobic Disorder - Diagnosis & Epidemiology
3. Types of Phobic Disorders
4. Case Study
5. Aetiology
6. Treatment
10

Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Introduction to Anxiety Disorders
1. Introduction to Anxiety Disorders (1/2)
11
Anxiety is normal…
• Anxiety is a common reaction to stress. It prevents
humans from being careless.
• Examples:
• Anxiety about your examination makes you study.
• Anxiety over her baby’s health makes a mother
care for her baby.
…however, in same situations anxiety can be abnormal
• If anxiety crosses a reasonable limit, it might become a disorder
• Examples:
• when one is so anxious that he/she has a breakdown in the
exam hall, forgetting everything
• when a mother is so anxious about her baby’s health, that she
spends day and night praying to God
Nature of Anxiety
Fear
• Fear is a basic emotion of human beings associated with
the perception of a real threatening situation and involves
the ‘fight or flight’ response activated by the sympathetic
nervous system.
• Example: If a street thug attacks you, you would feel intense
fear. Then, you would either run for dear life, or hit him back.
• Thus fear involves:
• cognition of the threatening object,
• subjective cognition of being in danger,
• physiological components like increased heart rate,
• behavioural components like running or hitting.
Anxiety
• Anxiety also involves subjective perception of threat,
physiological changes and some behavioural reaction.
• However, there is no immediate threat - you are
projecting the threatening situation in future and
reacting to it as if it is imminent. If you cannot go out of
your home because of apprehensions of an attack by a
hoodlum, it is anxiety.
• Anxiety serves an adaptive function - it prepares a person
for fight or flight if the danger really comes. But if the
person avoids the situation that in her perception may
cause the danger, and if such imagined situations are
unrealistic, then the effect becomes debilitating.

One may distinguish between adaptive
anxiety and pathological anxiety by
assessing the realistic probability of the
occurrence of the object of anxiety and
by assessing how dysfunctional it makes
the person.

Focus of this document
Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Introduction to Anxiety Disorders
1. Introduction to Anxiety Disorders (2/2)
13
Common Characteristics/Nature of Anxiety Disorders
• Cognition or subjective perception of danger – may be accompanied by
vivid, occasionally morbid, images of the difficulties encountered.
• Physiological Responses - through activation of sympathetic nervous
system. Usually includes dilated pupils, increased heart rate, trembling,
breathing discomfort, nausea etc.
• Behavioural Responses - usually a tendency to avoid the dreaded situation.
Except in OCD and sometimes PTSD, where repetitive behaviour is observed.
Anxiety
Disorder
Anxiety Disorder is a blanket term that covers a group of disorders characterized by
irrational fear of some thing or situation. The person is usually aware of the irrationality.
1
Panic Disorder
(with or without
agoraphobia)
2
Phobic Disorders
(specific or social)
3
Generalised
Anxiety Disorder
(GAD)
4
Obsessive
Compulsive
Disorder
(OCD)
5
Post Traumatic
Stress Disorder
(PTSD)
Types of Anxiety Disorders
(DSM IV TR)

Contents
4. Case Study
5. Aetiology
6. Treatment
14

Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Diagnosis and Epidemiology
2. Phobic Disorder Diagnosis and Epidemiology
15
Phobia
Derived from the name of the Greek god ‘Phobos’ who used to frighten his enemies, a
phobia is an intense and irrational fear of some object, living being or situation.
Diagnosis
To be diagnosed as suffering from phobic disorder (as per DSM IV–TR):
• one must have a persistent and disproportionate fear of some specific
object, social situation or crowded place that actually carries little danger.
• Exposure to the phobic stimulus almost invariably produces intense
anxiety response.
• Patient knows that the fear is unreasonable, but has no control on the
reaction.
• The phobic situation is usually avoided, or if forced to endured, may be
tolerated with great discomfort. When forced to encounter the phobic
stimulus, the reactions may be like panic attack, or a little less severe.
• The attention of the person facing the phobic object is directed completely
toward it, the affect is intense fear and the behavioural reaction is escape.
• As soon as the person escapes from the presence of the phobic stimulus,
the negative affect and accompanying physiological reactions subside.
• Thus, the flight reaction is reinforced as it provides relief from tension.
Epidemiology of Phobic
Disorder
• Not all phobias are of
equal prevalence.
• Social phobias are more
common than specific
phobias. While specific
phobias are estimated to
be around 4.5%, the
estimated prevalence of
social phobia is around 11%.
• Phobias, like panic
disorders, are more
common in women than
men.

Contents
4. Case Study
5. Aetiology
6. Treatment
16

Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Types of Phobia
3. Types of Phobia (as per DSM IV–TR)
17
1. Specific Phobia
• Specific phobias are the irrational
fear of specific objects, animals
or situations.
• Examples: fear of closed space
(claustrophobia), fear of fire
(pyrophobia) and even fear of
phobias (phobophobia.)
• Specific phobias can be divided
into some subtypes:
• animal type - cued by animals or
insects
• natural environment type - cued
by objects in the environment,
such as storms, heights, or water
• blood-injection-injury type -
cued by witnessing some invasive
medical procedure
• situational type - cued by a
specific situation, such as public
transportation, tunnels, bridges,
elevators, flying, driving, or
enclosed spaces
• other type - cued stimuli not
covered above, such as choking,
vomiting, or contracting an illness.
2. Social Phobia
• Social phobia is an irrational
intense fear of being exposed to
a crowd of people, specially
where one has to perform and be
evaluated.
• Often extreme feelings of shyness
and self-consciousness build into a
powerful fear, making it difficult to
participate in everyday social
situations.
• People with social phobia can
usually interact easily with close
and familiar persons, but meeting
new people, talking in a group, or
speaking in public can trigger the
phobic reaction.
• Often situations where one might
be evaluated become the phobic
situation.
• Normal individuals occasionally
have social anxieties, especially
under a judgmental situation, but a
person with social phobia often
becomes incapable of normal
social interaction.
3. Agoraphobia
• Agoraphobia refers to the fear of
public spaces where many people
congregate.
• Agoraphobia without history of
panic disorder has been given a
special emphasis in DSM IV–TR.
• It develops slowly and insidiously
from early adolescence or late
childhood, and gradually becomes
debilitating.
• Panic or Phobia?
• If it is a part of the panic attack, it
should be coded within Panic
disorders.
• If it occurs as a source of anxiety
and a strong urge to avoid, but
does not constitute a palpable
panic attack, it should be coded
within Phobia.

Contents
4. Case Study
5. Aetiology
6. Treatment
18

Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Case Study
4. Phobia Case Study – Specific Phobia
• Background
− Raju, 25, comes from a lower class family of fishermen.
− They earn livelihood by fishing in shallow backwater or rivulets branching out from the bigger rivers.
− He studied up to class 5 in the local school, but stopped due to poverty.
• Situation
− As a child, he accompanied his father to the backwaters, especially where they cultivated prawns.
− Sometimes, very rarely, crocodiles would swim in from the river with which the backwater was
connected. There were stories about crocodiles killing men around the village. Everybody had heard
these, but since crocodiles come rarely, everybody works in knee deep water without much anxiety.
• Problem
− Starting in early adolescence, Raju gradually became afraid of crocodiles, which then turned into
specific phobia - Herpetophobia. He was unable to work in the water, because if he sees any shadow,
even those of underwater plants and fish, he got uncontrollably scared.
− As Raju’s family has no land to cultivate, and Raju doesn’t have any other skill, he is unable to work. So
he has become financially dependent on his poor family.
− Raju understands that his fear is irrational, and he has never even heard of a man being attacked by a
crocodile in their locality.
− He understands that he is becoming a burden on his family; but he cannot overcome the intense fear.
− While he attributes the fear to the stories he had listened to in childhood, he knows that these are not
enough to provoke such strong reactions.
19

Contents
4. Case Study
5. Aetiology
6. Treatment
20

Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Aetiology
5. Phobic Disorder Aetiology
21
Causes of Phobic
Disorder
1
Biological Factors
1.1
Genetic Factors
1.2
Temperament
1.3
Evolutionary Factors
2
Psychological Factors
2.1
Psychoanalytical
Approach
2.2
Behavioural Approach
2.3
Cognitive Approach

5.1. Biological Factors
Biological factors are of less importance in phobias than in panic disorders.
22
1. Genetic Factors
• The genetic basis of phobias
has been suggested by some
studies, but it has not been
well established.
• At best the impact of genetic
factors is modest.
2. Temperament
• Temperament plays a
significant role in developing
phobia.
• Some children are
temperamentally jumpy or
easily aroused. This lability-
stability dimension is a
function of the
predisposition of the
autonomic activity.
• Those who are easily
aroused may have greater
chance of developing
anxiety disorders in later life.
3. Evolutionary Factors
• People are more likely to
develop fear of snakes or
heights than of books or cups.
• Thus, there seems to be a
‘preparedness’ to consider
some objects as more
phobic than others.
• This preparedness has been
retained by nature because
the primates who identified
these danger signals quickly
had a survival advantage.
• However, for the normal
person, the reality of the
danger is judged, while for
the phobic person the
reaction is exaggerated.

5.2.1. Psychoanalytical Approach
• The psychoanalytical approach emphasises
the role of unconscious needs and conflicts.
• Freud, in his description of fear of horses in
little Hans proposed that phobias are the
ego’s way of dealing with childhood conflict.
• For example, Hans could not resolve his
oedipal conflict properly and his fear of father
was displaced onto horses.
• Other psychoanalytical models attribute
phobias not to id drives, but to disastrous
interpersonal experiences. The mistrust and
generalised fear of environment seems to be
displaced on the phobic object or situation.
• Social phobia may be particularly well
explained by this latter view.
23
Psychoanalytical Explanation of Phobia
Repressing force
of the ego
Unconscious
conflict seeking
expression
Displacement on
the phobic object
Defensive Solution
Criticism of Psychoanalytical Approach
Learning theorists state that many phobias develop as result of association with a fear
eliciting object, and we don’t need to go deeper to the id impulses for explaining them.

5.2.2. Behavioural Approach: 1. Conditioning
• Watson and Rayner, through their experiments, conditioned little Albert to fear furry
objects by associating a rat with a loud bang.
• The learning theorists take this experiment on avoidance conditioning as the model
of phobic reactions.
• Phobia, as per this approach, is the end result of a process of a neutral stimulus
being turned into a phobic object due to unwarranted association in time with a
feared object.
• Initially the association creates the fear of the neutral stimulus, and then escape or
avoidance of the stimulus results in relaxation.
• This relaxation in turn acts as a reinforcer and maintains the phobia.
24
Explanation of Phobia by Conditioning
An object
elicits real fear
(Unconditioned
Stimulus)
Fear response
is attached to
a neutral
object
The neutral
object, over
time, begins
eliciting fear
(Conditioned
Stimulus)
Escape or
avoidance of
conditioned
object causes
relaxation
Relaxation
reinforces/
maintains the
phobia

5.2.2. Behavioural Approach: 2. Modeling
• Vicarious learning refers to the fact that a child models
behaviours, but also attitudes and emotions.
• The modeling theory proposes that phobias are learnt
via observational learning processes.
• Example: If a child repeatedly sees her mother being
afraid of something, the same would be observed in the
child also.
25
Explanation of Phobia by Modeling
Criticism of Learning Approach
• While learning theory justifies the origin of a number of phobias in
some cases, it is unable to explain all phobias.
• It is unable to explain phenomenon where there is a role of
preparedness (biological factor).
• Thus, learning may play a role in phobia, but it cannot be the
whole story.
Role model expresses
fear of a being or
thing
Child observes
repeatedly
Child develops fear of
the being or thing

5.2.3. Cognitive Approach
• Cognitive approach to phobias indicates a
greater selective attention towards the phobic
object.
• There is often an underlying core belief that
negative things are going to happen.
− Particularly in case of social phobia, but also in
other specific phobias, catastrophic outcomes
are believed to be inevitable, thus distorting the
reality for the person.
• The core belief may remain at a non-conscious
level, thus making it difficult to modify.
− However, if the person is taught to look into
her own erroneous assumptions and cognitive
biases, the distortion in thought process may
be identified.
26
Cognitive Explanation of Phobia
Core belief about
inevitable negative
events
Automatic
thoughts about
impending
catastrophe
Phobic Reaction
Core belief
justified

Contents
4. Case Study
5. Aetiology
6. Treatment
27

Psychopathology >> Clinical Features of Anxiety Disorders – Phobic Disorder >> Treatment
6. Phobic Disorder Treatment
28
Treatment of Phobic Disorder
1
Pharmocology
2
Psychological
Approaches
2.1
Psychoanalytical
Approach
2.2
Behavioural
Approach
2.3
Cognitive
Approach
As in case of panic disorder,
anxiolytics and anti-
depressants are used for
treating phobic disorders,
particularly social phobia.
They have greater
effectiveness
They try to unearth repressed
conflicts and deal with them at
a mature level than by
displacing them onto objects
and situations
• Cognitive approach is not the best option for specific phobic
disorders as the person already knows the unreasonableness of
her fear. Simply making her see the irrationality is of little help.
• Exposure to the situation seems to be essential for reduction of
specific phobia.
• However, cognitive behaviour therapy is useful in case of social
phobia. There are often automatic thoughts about self and others
underlying social phobia. Exploring such erroneous automatic
thought and making the client approach it from a new
perspective have been helpful in treating social phobia.
In real life the therapist might go for a
combination of therapies depending
upon the specific need of the client.
Methods like flooding, modeling,
systemic desensitization, and
relaxation techniques can be
used. Details on next page >>
<<

6.2.2. Behavioural Approaches (1/2)
29
Systematic Desensitization Process
Step 1
• Before starting
systematic
desensitisation,
teach your client
the relaxation
technique
scientifically.
Step 2
• Prepare the
‘hierarchies of
anxiety’, and
design situations
to expose her
gradually from
the lowest level
of anxiety to the
highest.
Step 3
• Start with the
lowest level
• Example: if client
is afraid of
snakes, show her
a cartoon picture
of a snake, which
would probably
not elicit phobic
responses in her.
• Ask her to relax
in the presence
of this picture,
and she should
be able to do it
well.
Step 4
• Show her a
perfectly realistic
photograph of a
snake
• She may be able
to relax even
though she is a
bit
uncomfortable
• .You continue till
she becomes
comfortable with
this step.
Step 5…
• Then show her a
3D picture
• She may become
disturbed.
• You continue
working with her
till she learns to
relax in front of it.
• Then you show
her a video – and
so on.
Final Step
• Finally, when she
is ready to take
her chance, take
her to a snake
park to show her
live snakes
• Ask her to relax
and enjoy.
• You continue till
she becomes
comfortable.
1. Systematic
Desensitization
A therapeutic technique based on behavioural approach where the client is exposed to
the phobic object or its image in graded stages, starting from a point where she is fully
relaxed, and then guided progressively toward staying relaxed even in situations where
she experienced intense fear

6.2.2. Behavioural Approaches (2/2)
30
• It is the opposite of graded exposure – as you expose your client straightaway to the feared
situation or object and ask her to relax.
• Example: This is the technique rural people take for teaching swimming to young boys. They throw the
protesting child in water with a cloth tightly wound around his waist. The child struggles and gasps in
water, and at last through random movements float up. He may be rescued at any moment with the
help of the cloth tied around his body. The same may be used with phobic people.
• Flooding needs to be used cautiously as there is a risk that the client may be traumatized.
2. Flooding
(Exposure
Therapy)
• A therapeutic technique based on behavioural approach where the client is exposed
all at once to the phobic object.
• She is instructed to relax instead of being afraid.
• Once she can relax in presence of the phobic object she is able to master her fear.
4. Modeling
• A therapeutic technique based on behavioural approach where the client observes
others in the group facing the same situation.
• Seeing others in a group facing the situation without fear may help the client in trying
to do the same.
3. Relaxation
Techniques
• A behavioural technique that includes any method, process, procedure, or activity
that helps a person to relax and to be free from stress and anxiety.
• Example: progressive muscular relaxation, controlled breathing, meditation ,
biofeedback etc.

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