Anxiety & fear-related disorder
Feeling apprehension (worried for no reason) about family,work,…
Last most days in a few months
GAD patient are aware of their condition, unlike Schizophrenia
Physical symptoms: Muscle tension, difficult sleeping & concentrating
How is data collected?
7 items, can be used as interview. 0-3
5/21 score is mild GAD
What does it measures?
Ask how often you feel anxiety-related symptoms over 2 weeks
Strong test-retest reliability (test produce same when done again) ⇒ reliable
Quick + easy to use
Can't measure changes in severity of symptoms over a long time. Only measure mood at that time.
Fear in places/situation hard to escape (subway). Fear of panic attack or embarrrassing moment in the places
Stressed if in those place
Irrational fear for certain situation or object.
Most phobia increase heart rate, but blood-injection-injury phobia reduce heart rate = fainting
How to collect data?
4 point likert scale (0-never, 3 - always)
18 sample situations, imagine the scenario
What does it measure?
Measure 27 possible response to stimuli. Situational anxiety (reaction at the event), anticipation anxiety (reaction build up to the event)
Behavioral
Biological
Cognitive
Useful for Spanish speaking culture
Score between BIPI and FQ matched
Has 18 situations and measure patients cognitive, behavior and physical reaction. Doctor can build personalize treatment for specific symptoms
Self-report data, not accurate
Patient predict how they would react, not researcher observe how they react
Make BIPI for Spanish people
Phobia group complete BIPI and FQ (Fear Questionnaire) to double check answers.
Strong correlation with BIPI and FQ about blood phobia. Blood phobia people get higher score than healthy people.
Factor analysis help research eliminate bad questions that can't identify blood phobia
More female than male
Runs in family and MZ twins
We are designed to develop some fear easier (spider,…)
When sperm or egg cell got mutations
Affect child mental health even though their parents is normal
NTRK3 genes
90% people with fear-related disorder have duplication of chromosome 15 (DUP25) + duplicate NTRK3 gene
NTRK3 gene link stimuli to emotional arousal, so overexpressed gene cause high noradrenaline level + anxiety
Normal NTRK gene contain 100% of itself, overexpressed NTRK gene has part of other genes in it
Transgenic mice over-expressed NTRK3 has anxiety behavior
Ignore nurture. Environment affect gene expression + 60% of people with DUP25 doesn’t develop anxiety
To find a difference between blood phobia and injection phobia cause they too similar
Ppt watched a surgery video and had finger-prick blood test
Findings:
Blood phobics more likely to have both phobias, while most injection phobics don’t have blood phobia
Blood phobics more afraid of their phobia and faint more than injection (blood phobic heart rate is lower than injection)
Blood phobics more likely to have parents with blood phobics
Objective data: record how long ppt endure the video rather than ask ppt how long they think they can deal with phobias
Not realistic, lack ecological validity. Ppt watched surgery video, not the same when they face their own blood in an accident. Hence data is not true in real life
Classical conditioning associate involuntary response to stimulus, operant associate behavior with consequence
Classical (classic) conditioning e.g: A loud thunder when a tree crash into your house, next time you hear thunder you feel scared
Operant conditioning and negative reinforcement. Associate a behavior with consequence + repeat certain behavior to avoid negative consequences.
Need repetition of stimulus to make it a phobia
Operant e.g: kid bitten by dog, next time see dog he avoids it, he’s safe so he continue to avoid dogs until he believe that he is only safe when no around dog
(Stimulus and response. Unconditioned stimulus and response are natural things. Conditioned response is learned towards conditioned stimulus)
Nurture. A boy learn to fear the rat by associating with fear for loud noise.
Phobias can be learned, so people may find ways to unlearn fear
Ignore nature role. We are genetically prepared to learn some phobias easier than other (we evolved to fear spider and snakes cause they dangerous)
Individual differences. How we interpret event matter more than what the event is. Everyone is different
To see whether a fear of rat could be classically conditioned with loud noise
Find out the effect of time on learned fears and how to remove fear
Ppt: 9 month old boy, scared of loud noise
Qualitative data (behavior) was recorded
Before
Hit steel bar with a hammer that cause loud noise (unconditioned stimulus)
Cried (unconditioned response)
Was not afraid of rat (neutral stimuli)
Procedure
Shown the rat
As the boy approach the rat, a loud noise created
The boy got scared
After third trail: the boy whimpered when see rat
After fifth trail: the boy avoided the rat
Result
Got a bit scared with white fluffy things like rat (Watson’s hair) But only when paired with loud noise
After more time, the boy scared at fur and animals only by seeing them
Mother withdrew + rs did not reverse the fear
Longitudinal research. Observed behavior within 3 months, know how fear intensity change overtime.
Qualitative, range of behavior like whimpering, crying.
Lab setting, fear responses are greater in unfamiliar setting
Only one boy —> Girls might act different, other might form fear differently
Bad Ethics
Deception of true aim, no real informed consent
Psychological harm, researchers created a fear and didn’t reverse it
Caused by unresolved conflict from childhood. Child have problem when pooping (3 years old), become anal-retentive and fixated at that stage => develop fear for germs if not clean excessively
Defense mechanism + coping strategy from conflict between id and superego.
Transfer id’s desires into acceptable behavior. “Kid wants to kill his father, develop blood phobia as a way to express that desire”
At age 5, male kid wants to spend time with mother (Oedipus complex). Fear of father cut off their penis (castration anxiety). Normally resolved by Identification (child wanting to be like father rather than kill father), but unresolved fear will transfer into things which has symbolic connection to the anxiety.
(Hans scared of horses cause big dick like his dad)
Develop new treatment, psychoanalysis (free association = let patient talk endlessly, which leads to unconscious mind)
Unscientific, some people know the cause of their phobia. Not all phobia developed during childhood
Weak evidence. Little Hans case study only has evidence from his father, who has interest in Freud
Psychodynamics are hidden factors in our subconscious that affect behavior.
Behavior is influenced by unconscious drives, desires, and conflicts since childhood.
Phobias are a defense mechanism against the unresolved conflicts between the id and the superego. The anxiety can be transferred to an object, person which has a symbolic connection to the anxiety
Id: bad guy, driven by desire and not responsible
Superego: good guy, ethical and set moral standards for ego to follow. Punish ego with feelings of guilt if ego did bad things
Ego: the middle man, control and balance the 2. Help express id in socially acceptable way.
Protect us from superego punishment by defense mechanism
Protect us when superego punish us with feelings of shame, guilt
Often direct the feelings to something else (X can not remember his friend’s dead, the brain hides the sadness away)
Allow id desires to be expressed in a socially acceptable way
Id biggest desires = Sexual pleasure & aggression
Ego use dreamwork (turn unconscious desires into dreams). This is wish fulfilment (the id’s desires are satisfied)
What we remember from dreams reveal our unconscious desire
Each stage focus on different erogenous zone (sexually aroused body part when touch)
Birth: mouth is erogenous zone, like suck stuff
3 year: anal, like popping
5 year: touching genitals, want attention from opposite gender
Each psychosexual stage has a conflict, if person can’t overcome conflict it can develop bad personality traits
Investigate the cause of phobia of white horse in a 5 year old little Hans
Little Han’s father is a fan of Freud.
During the time Han saw a died horse —> made him scared of horse:
He was at his phallic stage of psychosexual development. He played with his penis. Mother threatened to cut off his penis —> fear of castration
Develop conflict with father, he like to cuddle with mother but father didn’t want that
Han transfer fear of castration into fear that horse can bite off his penis
Han dreamed about getting a bigger penis —> want to become his father
Case study, lots of data
Longitudinal study, Freud stayed updated on Han until his phobia go away, observe behavior overtime
Only 1 ppt
Han’s dad is a Freud fan, Han might tell what happened in a way to match with Freud theory
Little Han story was known across the town, might affect his later life. (No confidentiality)
Replacing unwanted response to stimuli with a wanted response
E.g: Peter scared of rabbit
Jones let Peter eat candy while putting the rabbit closer each time
Rabbit = conditioned stimulus → fear
Candy = uncondtion stimulus → happy
Eat candy with rabbit nearby → happy
Rabbit → no more fear, happy
Patient imagine stimuli until they feel comfortable with it
Combined fear hierarchy and reciprocal inhibition
Gradual exposure of stimuli until not afraid anymore
Reciprocal inhibition: you cannot feel anxious while also feeling relaxed and happy
Use deep muscle relaxation technique to relax patient, then patient imagine stimuli
(Anti-anxiety drugs can be used to be relax as well)
Then make fear hierarchy, move up the fear list when patient is able to tolerate the lower ones
Supported by animal research. Let cats have electric shock in a cage. Then feed them food, after time cat associate cage with food and not electric shock. So Counter Conditioning works
Fear hierarchy might not be necessary (time taking)
Implosive therapy expose patient to high stress stimuli right away, take less time (but stressful)
Too reductionist. Person belief affect anxiety
(avoidant behavior caused by thinking “I don’t deserve good things”)
Anxiety came from dysfunctional thinking pattern (patient are thinking wrong)
CBT challenge the realism of anxiety thoughts, making patient realize their fear is not real
CBT remove inaccurate belief and replace it with positive thoughts
Fear structure: mental framework about reacting to a threat
e.g:
Feared stimulus: snake
Behavior response: heart beating fast
Meaning of such response: the snake might bite me, so i’m scared
Bad stimuli cause avoidance. They never accept positive quality of the feared object again
CBT give patient positive thoughts about the feared object
Applied tension (AT): behavior technique to reduce dizziness and fainting for blood&injury phobic
Tense muscle and relax them, repeat multiple time
BII phobia reduce heart rate and cause fainting
Blood phobic have higher disgust response , disgust triggers parasympathetic nervous system to reduce blood pressure
To investigate “mechanism of change” (things of therapy that reduce phobia) in 9 week of applied tension (AT) and manualized CBT
1 Hispanic male 42 years old
Phobia for medical places for 20 years, experience fainting during blood test
His kid has autism, but he’s afraid of hospital so can’t go to his kid’s appointment, which he regrets
Interview challenging times in his life
Watching family member death
Witness family member faint during medical procedure
Living with grandma who is obsessed with medical emergencies, he is affected
Questionnaire measure level of anxiety
BAI + BDI (anxiety)
BISS (BII test)
SUDS (Discomfort ratings)
Applied tension: sit down, tense muscle around body for 10 secs, release for 30 secs, repeat
9 CBT & AT & fear hierarchy
Went through each stage in hierarchy, move up when SUDS (discomfort rating) is low
Completed homework (muscle tension workout, watch video about blood test)
Complete PER , wrote down his thoughts & emotions about blood every session (to assess his improvement overtime)
Received psychoeducation about common phobia
Can take blood test without fear, go to hospital
Anxiety levels dropped against medical stimuli
Quantitative and qualitative data: Questionnaire and interview => more data to analyse
Useful
Ethics. Hidden name + only move on hierarchy once he’s fine (psychological protection)
Too idiographic, only 1 ppt and 1 phobia
No control group
Self-reported data, reduce validity
Application. Blood injection injury phobia (BII) can be treated outside of hospital setting. But BII is harder to treat than other phobias, increase treatment session.
Feeling apprehension (worried for no reason) about family,work,…
Last most days in a few months
GAD patient are aware of their condition, unlike Schizophrenia
Physical symptoms: Muscle tension, difficult sleeping & concentrating
How is data collected?
7 items, can be used as interview. 0-3
5/21 score is mild GAD
What does it measures?
Ask how often you feel anxiety-related symptoms over 2 weeks
Strong test-retest reliability (test produce same when done again) ⇒ reliable
Quick + easy to use
Can't measure changes in severity of symptoms over a long time. Only measure mood at that time.
Fear in places/situation hard to escape (subway). Fear of panic attack or embarrrassing moment in the places
Stressed if in those place
Irrational fear for certain situation or object.
Most phobia increase heart rate, but blood-injection-injury phobia reduce heart rate = fainting
How to collect data?
4 point likert scale (0-never, 3 - always)
18 sample situations, imagine the scenario
What does it measure?
Measure 27 possible response to stimuli. Situational anxiety (reaction at the event), anticipation anxiety (reaction build up to the event)
Behavioral
Biological
Cognitive
Useful for Spanish speaking culture
Score between BIPI and FQ matched
Has 18 situations and measure patients cognitive, behavior and physical reaction. Doctor can build personalize treatment for specific symptoms
Self-report data, not accurate
Patient predict how they would react, not researcher observe how they react
Make BIPI for Spanish people
Phobia group complete BIPI and FQ (Fear Questionnaire) to double check answers.
Strong correlation with BIPI and FQ about blood phobia. Blood phobia people get higher score than healthy people.
Factor analysis help research eliminate bad questions that can't identify blood phobia
More female than male
Runs in family and MZ twins
We are designed to develop some fear easier (spider,…)
When sperm or egg cell got mutations
Affect child mental health even though their parents is normal
NTRK3 genes
90% people with fear-related disorder have duplication of chromosome 15 (DUP25) + duplicate NTRK3 gene
NTRK3 gene link stimuli to emotional arousal, so overexpressed gene cause high noradrenaline level + anxiety
Normal NTRK gene contain 100% of itself, overexpressed NTRK gene has part of other genes in it
Transgenic mice over-expressed NTRK3 has anxiety behavior
Ignore nurture. Environment affect gene expression + 60% of people with DUP25 doesn’t develop anxiety
To find a difference between blood phobia and injection phobia cause they too similar
Ppt watched a surgery video and had finger-prick blood test
Findings:
Blood phobics more likely to have both phobias, while most injection phobics don’t have blood phobia
Blood phobics more afraid of their phobia and faint more than injection (blood phobic heart rate is lower than injection)
Blood phobics more likely to have parents with blood phobics
Objective data: record how long ppt endure the video rather than ask ppt how long they think they can deal with phobias
Not realistic, lack ecological validity. Ppt watched surgery video, not the same when they face their own blood in an accident. Hence data is not true in real life
Classical conditioning associate involuntary response to stimulus, operant associate behavior with consequence
Classical (classic) conditioning e.g: A loud thunder when a tree crash into your house, next time you hear thunder you feel scared
Operant conditioning and negative reinforcement. Associate a behavior with consequence + repeat certain behavior to avoid negative consequences.
Need repetition of stimulus to make it a phobia
Operant e.g: kid bitten by dog, next time see dog he avoids it, he’s safe so he continue to avoid dogs until he believe that he is only safe when no around dog
(Stimulus and response. Unconditioned stimulus and response are natural things. Conditioned response is learned towards conditioned stimulus)
Nurture. A boy learn to fear the rat by associating with fear for loud noise.
Phobias can be learned, so people may find ways to unlearn fear
Ignore nature role. We are genetically prepared to learn some phobias easier than other (we evolved to fear spider and snakes cause they dangerous)
Individual differences. How we interpret event matter more than what the event is. Everyone is different
To see whether a fear of rat could be classically conditioned with loud noise
Find out the effect of time on learned fears and how to remove fear
Ppt: 9 month old boy, scared of loud noise
Qualitative data (behavior) was recorded
Before
Hit steel bar with a hammer that cause loud noise (unconditioned stimulus)
Cried (unconditioned response)
Was not afraid of rat (neutral stimuli)
Procedure
Shown the rat
As the boy approach the rat, a loud noise created
The boy got scared
After third trail: the boy whimpered when see rat
After fifth trail: the boy avoided the rat
Result
Got a bit scared with white fluffy things like rat (Watson’s hair) But only when paired with loud noise
After more time, the boy scared at fur and animals only by seeing them
Mother withdrew + rs did not reverse the fear
Longitudinal research. Observed behavior within 3 months, know how fear intensity change overtime.
Qualitative, range of behavior like whimpering, crying.
Lab setting, fear responses are greater in unfamiliar setting
Only one boy —> Girls might act different, other might form fear differently
Bad Ethics
Deception of true aim, no real informed consent
Psychological harm, researchers created a fear and didn’t reverse it
Caused by unresolved conflict from childhood. Child have problem when pooping (3 years old), become anal-retentive and fixated at that stage => develop fear for germs if not clean excessively
Defense mechanism + coping strategy from conflict between id and superego.
Transfer id’s desires into acceptable behavior. “Kid wants to kill his father, develop blood phobia as a way to express that desire”
At age 5, male kid wants to spend time with mother (Oedipus complex). Fear of father cut off their penis (castration anxiety). Normally resolved by Identification (child wanting to be like father rather than kill father), but unresolved fear will transfer into things which has symbolic connection to the anxiety.
(Hans scared of horses cause big dick like his dad)
Develop new treatment, psychoanalysis (free association = let patient talk endlessly, which leads to unconscious mind)
Unscientific, some people know the cause of their phobia. Not all phobia developed during childhood
Weak evidence. Little Hans case study only has evidence from his father, who has interest in Freud
Psychodynamics are hidden factors in our subconscious that affect behavior.
Behavior is influenced by unconscious drives, desires, and conflicts since childhood.
Phobias are a defense mechanism against the unresolved conflicts between the id and the superego. The anxiety can be transferred to an object, person which has a symbolic connection to the anxiety
Id: bad guy, driven by desire and not responsible
Superego: good guy, ethical and set moral standards for ego to follow. Punish ego with feelings of guilt if ego did bad things
Ego: the middle man, control and balance the 2. Help express id in socially acceptable way.
Protect us from superego punishment by defense mechanism
Protect us when superego punish us with feelings of shame, guilt
Often direct the feelings to something else (X can not remember his friend’s dead, the brain hides the sadness away)
Allow id desires to be expressed in a socially acceptable way
Id biggest desires = Sexual pleasure & aggression
Ego use dreamwork (turn unconscious desires into dreams). This is wish fulfilment (the id’s desires are satisfied)
What we remember from dreams reveal our unconscious desire
Each stage focus on different erogenous zone (sexually aroused body part when touch)
Birth: mouth is erogenous zone, like suck stuff
3 year: anal, like popping
5 year: touching genitals, want attention from opposite gender
Each psychosexual stage has a conflict, if person can’t overcome conflict it can develop bad personality traits
Investigate the cause of phobia of white horse in a 5 year old little Hans
Little Han’s father is a fan of Freud.
During the time Han saw a died horse —> made him scared of horse:
He was at his phallic stage of psychosexual development. He played with his penis. Mother threatened to cut off his penis —> fear of castration
Develop conflict with father, he like to cuddle with mother but father didn’t want that
Han transfer fear of castration into fear that horse can bite off his penis
Han dreamed about getting a bigger penis —> want to become his father
Case study, lots of data
Longitudinal study, Freud stayed updated on Han until his phobia go away, observe behavior overtime
Only 1 ppt
Han’s dad is a Freud fan, Han might tell what happened in a way to match with Freud theory
Little Han story was known across the town, might affect his later life. (No confidentiality)
Replacing unwanted response to stimuli with a wanted response
E.g: Peter scared of rabbit
Jones let Peter eat candy while putting the rabbit closer each time
Rabbit = conditioned stimulus → fear
Candy = uncondtion stimulus → happy
Eat candy with rabbit nearby → happy
Rabbit → no more fear, happy
Patient imagine stimuli until they feel comfortable with it
Combined fear hierarchy and reciprocal inhibition
Gradual exposure of stimuli until not afraid anymore
Reciprocal inhibition: you cannot feel anxious while also feeling relaxed and happy
Use deep muscle relaxation technique to relax patient, then patient imagine stimuli
(Anti-anxiety drugs can be used to be relax as well)
Then make fear hierarchy, move up the fear list when patient is able to tolerate the lower ones
Supported by animal research. Let cats have electric shock in a cage. Then feed them food, after time cat associate cage with food and not electric shock. So Counter Conditioning works
Fear hierarchy might not be necessary (time taking)
Implosive therapy expose patient to high stress stimuli right away, take less time (but stressful)
Too reductionist. Person belief affect anxiety
(avoidant behavior caused by thinking “I don’t deserve good things”)
Anxiety came from dysfunctional thinking pattern (patient are thinking wrong)
CBT challenge the realism of anxiety thoughts, making patient realize their fear is not real
CBT remove inaccurate belief and replace it with positive thoughts
Fear structure: mental framework about reacting to a threat
e.g:
Feared stimulus: snake
Behavior response: heart beating fast
Meaning of such response: the snake might bite me, so i’m scared
Bad stimuli cause avoidance. They never accept positive quality of the feared object again
CBT give patient positive thoughts about the feared object
Applied tension (AT): behavior technique to reduce dizziness and fainting for blood&injury phobic
Tense muscle and relax them, repeat multiple time
BII phobia reduce heart rate and cause fainting
Blood phobic have higher disgust response , disgust triggers parasympathetic nervous system to reduce blood pressure
To investigate “mechanism of change” (things of therapy that reduce phobia) in 9 week of applied tension (AT) and manualized CBT
1 Hispanic male 42 years old
Phobia for medical places for 20 years, experience fainting during blood test
His kid has autism, but he’s afraid of hospital so can’t go to his kid’s appointment, which he regrets
Interview challenging times in his life
Watching family member death
Witness family member faint during medical procedure
Living with grandma who is obsessed with medical emergencies, he is affected
Questionnaire measure level of anxiety
BAI + BDI (anxiety)
BISS (BII test)
SUDS (Discomfort ratings)
Applied tension: sit down, tense muscle around body for 10 secs, release for 30 secs, repeat
9 CBT & AT & fear hierarchy
Went through each stage in hierarchy, move up when SUDS (discomfort rating) is low
Completed homework (muscle tension workout, watch video about blood test)
Complete PER , wrote down his thoughts & emotions about blood every session (to assess his improvement overtime)
Received psychoeducation about common phobia
Can take blood test without fear, go to hospital
Anxiety levels dropped against medical stimuli
Quantitative and qualitative data: Questionnaire and interview => more data to analyse
Useful
Ethics. Hidden name + only move on hierarchy once he’s fine (psychological protection)
Too idiographic, only 1 ppt and 1 phobia
No control group
Self-reported data, reduce validity
Application. Blood injection injury phobia (BII) can be treated outside of hospital setting. But BII is harder to treat than other phobias, increase treatment session.
