Anxiety & Fear-Related Disorders

Anxiety & Fear-Related Disorders

Get-to-Know-You Round Robin

• Introductions
  • Name.
  • Favorite holiday movie.
  • Favorite and least favorite part of the class so far.
  • One characteristic that helps with teamwork.

Jot Thoughts – Team Building

• Dream Vacation Spots
  • Take 1 minute to think of as many dream vacation spots as possible; do not write them down.
• Cover the table with as many ideas as possible in 2 minutes.
  • Each person says their idea first, then writes it on a sticky note.
  • Put the sticky note in the middle of the table without overlapping.
  • Each person must come up with at least 4 ideas.
• Sort the vacation spots.
  • Each person gives an idea of how to sort the cards.
  • Vote on which sorting method is best.
  • Suggest where each sticky note would go, and the group reaches a consensus.

Diagnostic Criteria – Anxiety & Fear-Related Disorders

• Disorders including a build-up of arousal that cannot be diminished.
  • Generalized Anxiety Disorder (GAD).
  • Agoraphobia.
  • Specific Phobia (Blood-Injection-Injury).

Generalized Anxiety Disorder (GAD)

• Intense, persistent, and unreasonable anxiety about everyday things.
  • Must experience symptoms almost every day for several months.
  • Must include:
    • General sense of apprehension.
    • Excessive worries about family, health, finance, school, or work.
    • Distress disrupting daily functioning.
  • Symptoms:
    • Physical – muscle aches & pains, insomnia, digestive issues.
    • Behavioral – restlessness, irritability.
    • Affective - nervousness.
    • Cognitive – inability to concentrate.
  • People with GAD often have good insight into their condition.
    • They know their anxieties are irrational but cannot control their thoughts, which is distressing.
  • Prevalence: 2-5%.
    • In MO, 9% in females, 4% in males.

Generalized Anxiety Disorder Assessment (GAD-7)

• 7-item questionnaire.
• Can be used as a semi-structured interview.
• Items are on a 4-point scale, from 0-3.
• Questions are about the last 2 weeks.
• Those with GAD scored $14.4$, on average, and those without GAD scored $4.9$, on average.
  • Strengths:
    • Strong test-retest reliability.
    • Quick & easy to use.
  • Weaknesses:
    • May not show severity of symptoms.

Agoraphobia

• A person’s fear response will be triggered by situations where “escape may be difficult” or help may not be available.
  • Ex: using public transportation, being in crowds, being outside the home alone.
  • Must experience symptoms almost every day for several months.
  • People with Agoraphobia avoid such situations due to fear of having a panic attack or showing other symptoms in public.

Specific Phobia (Blood-Injection-Injury Phobia)

• Irrational and/or excessive fear in the presence of blood, injections (needles), or injuries.
  • Many phobias cause an increase in heart rate and blood pressure, but BII causes a sudden decrease in blood pressure, causing them to faint.
  • $46\%$ say they have a first-degree relative with BII.
  • $86\%$ say BII causes significant impairment to their daily functioning.

Blood Injection Phobia Inventory (BIPI)

• Lists 18 situations, and participants answer 27 questions of symptoms on a rating scale from 0-3 of how often they feel that symptom in the given situation.
  • Situation Examples:
    • When I see an injured person after an accident, bleeding in the road, or on the television…
    • When I think I have to accompany a relative to have a blood test…
  • Question Examples:
    • “I think that people will notice how distressed I feel”.
    • “My palms and armpits sweat”.
    • “My legs and/or hands shake”.
  • Strengths:
    • High validity in Spanish-speaking cultures, too (Mas et al., 2010).
    • Wide range of situations and symptoms that it measures.
  • Weaknesses:
    • Subjective, because it is self-reported.

Mas et al. (2010)

• Aim to develop a valid & reliable measure of blood phobia for people who speak Spanish.
  • 39 people.
    • All participants were from Spain.
  • Matched pairs.
    • Phobic group & non-phobic group.
  • Originally gave 50 situations and decided on 18 that had the highest reliability & validity.
  • Took the 50-question BIPI AND the Fear Questionnaire (Marks & Matthews, 1979).
    • Found a positive correlation between the 2.
  • Strengths:
    • Used rigorous statistical analysis to find the most valid 18 situations.
  • Weaknesses:
    • Generalizability – used 3x as many females as males.

Diagnostic Criteria Practice Question

• Evaluate the Blood Injection Phobia Inventory (BIPI), with reference to one research study, including a discussion of psychometric tests.

Biological Explanation – Anxiety & Fear-Related Disorders

• Before 2003 (when the Human Genome Project was created), scientists had to do twin, family, and adoption studies to study genetic inheritance.
  • Ost (1992): Blood phobia may be more heritable than other specific phobias.

Ost (1992)

• Used self-report data & behavioral tests to see if blood-injection phobias should be separated into blood phobias and injection phobias.
  • 81 people with blood phobia.
  • 59 people with injection phobia.
  • Data from another study by Ost (1987) of other phobias was used as a comparison.
  • Self-report used to:
    • Gather data about the origin of the phobia, age of onset, and family history.
    • Participants self-reported physical & cognitive reactions in potential anxiety-arousing situations.
  • Behavioral Test: blood phobics watched a video of a surgery and injection phobics took a finger-prick test.
    • Researchers rated fainting on a scale of 0-4.
    • Participants then self-reported anxiety on a scale of 0-10.
  • Conclusions:
    • There are more similarities than differences between people with Blood phobia and Injection phobia, so they should NOT be separated.
    • Blood phobia may have a stronger genetic component.
  • Strengths:
    • Use of both objective & subjective data.
    • Internal validity – diagnoses were checked prior to the study on another measure.
  • Weaknesses:
    • Lack of Ecological Validity: those with blood phobia watched a video, which may be different from seeing real blood.
    • Internal validity – diagnoses of first-degree relatives may not have been accurate.

Transgenic Mice

• Mice’s genome was altered and those that overexpressed the NTRK3 gene showed increased anxious behavior and panic when showed threatening stimuli.
  • Which is also present in humans.

Biological Explanation Questions

• Imagine you are one of the participants in Ost’s study. You completed the interview and questionnaire, then you find out about the behavioral tests. How would you feel? Would you withdraw at this point? What are your thoughts on the ethics of this study?
• Why do you think scientists use mice for genetic research?
• Explain one weakness of explanations for anxiety & fear-related disorders from the nature side of nature vs. nurture.
• Compare two research methods used to investigate phobias.

Conditioning Round Robin

• Each person say 1 thing they remember about:
  • Classical Conditioning.
  • Operant Conditioning.
  • Pavlov.
  • Little Albert.
  • Saavedra & Silverman.

Psychological Explanation – Anxiety & Fear-Related Disorders

Behavioral Explanation

• Classical conditioning & operant conditioning.
  • Classical Conditioning: 2 stimuli become associated, where a neutral stimulus now causes a conditioned response.
  • Operant Conditioning: Being rewarded for behaviors will increase you doing it in the future. Being punished will decrease you doing it.
• Before Conditioning
  • $UCS \rightarrow UCR$
• During Conditioning
  • $NS + UCS \rightarrow UCR$
• After Conditioning
  • $CS \rightarrow CR$

Psychodynamic Explanation

• Without therapy, people will not know about these phobias because they are stored in the unconscious.
  • These problems start in early infancy and childhood.
  • 3 parts to personality:
    • Id: first part, basic needs.
    • Ego: At age 2, rational part.
    • Superego: Ages 3-5, morality.
      • Includes the conscience.
  • Psychosexual Stages: Freud believed each stage came with its own conflicts. If the conflicts were not overcome, it would lead to bad personality traits.
    • Name | Age | Erogenous Zone | Pleasure | Conflict
      | ----------- | ----------- | ----------- | ----------- | -----------
      | Oral | Birth-18 mos | Mouth | Sucking & biting | Weaning |
      | Anal | 18 mos-3 yrs | Anus, Rectum | Withholding & Expelling feces | Potty Training |
      | Phallic | 3-5/6 years | Genitals | Touching genitals & receiving attention from opposite-sex parents | Oedipus Complex |

Little Hans

• Longitudinal Case Study to describe the development of a phobia of white horses in a 5-year-old boy.
  • Hans used to talk a lot about “widdlers” (his word for penis), asking if other adults and/or animals had them.
  • At 3.5 years, his mother said if he kept talking about it, the doctor would cut off his penis.
    • Starting his castration anxiety.
  • Hans had a fear of white horses.
    • He was distressed when out with his mom.
    • His father thought this fear was because Hans wanted to be home with his mother AND because horses had large penises.
  • Strengths:
    • Qualitative Data.
    • Freud had a lot of information from the dad.
  • Weaknesses:
    • Case study.
    • Could’ve been genetic.

Explanations Posters

• You are going to create a poster comparing & contrasting the biological & psychological explanations for the 4 disorders we have covered so far.
  • Each person must cover 1 bio explanation and 1 psych explanation.
  • Must be large print, colorful, etc.

Psychological Treatments – Anxiety & Fear-Related Disorders

Behavioral Therapy

• Mary Cover Jones & Little Peter: After Little Albert, Mary thought she could do the opposite and counter-condition a phobia OUT of a child.
  • Before Conditioning:
    • $Candy (UCS) \rightarrow Happy Peter (UCR)$
  • During Conditioning:
    • $Rabbit (NS) + Candy (UCS) \rightarrow Happy Peter (UCR)$
  • After Conditioning:
    • $Rabbit (CS) \rightarrow Happy Peter (CR)$

Systematic Desensitization

• Combines a fear hierarchy and ‘reciprocal inhibition’.
  • Reciprocal Inhibition: Relaxation & fear responses cannot co-exist.
    • Can use deep muscle relaxation or anti-anxiety medication.
  • In the first session, patient & therapist create a hierarchy of least distressing à most distressing.
    • Then therapy starts with the least distressing.
    • This can be in vivo (IRL) or through imagination.
  • Strengths:
    • Supported by animal studies – cat study.
    • Longitudinal evidence – Lipsedge et al. (1973): Found that using barbituates with SD made it more effective, but SD was still more effective than just barbituates.
  • Weaknesses:
    • The fear hierarchy may be unnecessary, so costly.
    • Could use Flooding Therapy.
    • Reductionist – does not take irrational beliefs into account.

Behavioral Therapy - Agoraphobia

• Imagine you are a behavioral therapist working with a client, Audrey, who has agoraphobia. In your first session, you work together to create a fear hierarchy, including six situations involving being alone in public places. Audrey ranks the situations from least to most distressing. What might these situations be and what order might she put them in?
• Urzila has been diagnosed with agoraphobia. She is unable to walk beyond the end of her street, has not used public transportation for ten years and the thought of going on holiday makes her sick. Outline how a behavioral therapist might treat Urzila’s phobia.
• Explain one ethical strength of using systematic desensitization as a treatment for Agoraphobia.

Cognitive Behavioral Therapy (CBT)

• Challenging unhelpful beliefs and the way people behave.
  • Cognitive: Breaking down cognitive fear structures.
    • Ex: phobia of a dog = fear of big teeth, furry things, barking.
  • Behavioral:
    • Exposure Therapy.
    • Applied Tension: Tensing muscles, holding for 10-15 seconds, releasing for 20-30 seconds, and repeating 5 times.

Chapman & DeLapp (2013)

• Treating blood- injection-injury phobia using cognitive-behavioral therapy with applied tension.
  • Kevin Chapman is a licensed clinical psychologist in Kentucky, focused on using CBT for anxiety disorders.
  • Ryan DeLapp specializes in treating anxiety & depression in all ages.
• Aim: Provide insight into treatment of BII phobia through a 9-week course of applied tension and CBT for an adult male patient.
• Case study, using quantitative AND qualitative data.
• T was a Hispanic male, aged 42. He self-referred following more than 20 years of intense fear/panic in medical situations, such as doctors’ waiting rooms, and suffered from vasovagal syncope during blood tests and other procedures. Her perceived these procedures as dangerous and experiences distress relating to his physical symptoms, which includes racing heart, hot flashes, cold chills, dizziness, and unsteadiness, additional to the fainting.
• Used a diagnostic interview, Beck Anxiety Inventory, Fear Survey Schedule II, and Blood-Injection Symptom Scale to confirm his diagnosis.
• T completed 9 sessions of CBT.
  • T completed homework between sessions, including reading assignments and applied tension.
  • Sessions 1-3: Psychoeducation & the importance of homework.
  • Session 4: Created a 10-item fear hierarchy.
  • Session 5: T did the 1st item at home, while doing the applied tension.
    • Rated his distress on the Subjective Units of Discomfort Scale (SUDS) – 0-100.
  • Session 6: T completed item 2 and used the SUDS to monitor anxiety during the process.
  • Session 7: T was able to prick his own finger to check for blood sugar.
  • Session 8: T & therapist watched people give blood.
    • T did not use AT and did not feel faint.
  • Session 9: T did his own blood test (item 10).
    • Used AT at the start, then felt fine.
• 4 months later, T was doing well.
• 10 months later, still doing well.
• 12 months later, completed post-treatment questionnaires, which showed massive progress.
• Conclusions:
  • Psychoeducation, objective recording, cognitive restructuring, and graduated exposure were highly effective when combined with applied tension in the treatment of a man with severe BII phobia.
  • A highly individualized treatment plan was most effective.
• Strengths:
  • Use of qualitative & quantitative data.
  • Therapists can generalize to their own clients because they gave so much detailed information.
• Weaknesses:
  • SUDS was all self-reported.
  • T had social anxiety, and may have been more likely to give socially desirable answers.
  • Lack of a control group.

CBT Questions

• Tamwar had always wanted to be a doctor, but when he was asked to perform a blood test in front of other students, he fainted. Tamwar was upset and embarrassed and decided to research why this happened in the hope that he could somehow stop it from happening again
• Explain one biological reason why Tamwar might have fainted at the sight of blood (2)
• Explain one way that Tamwar could stop himself from fainting at the sight of blood in the future (4)
• Phoebe and Freddie are discussing whether Chapman & DeLapp (2013) took an idiographic or nomothetic approach in their study. Phoebe thinks they took an idiographic apparoach, but Freddie thinks, because they collected SUDS scores, the study was nomothetic. Explain whether you agree with Phoebe or Freddie. (4)