Download Fundamentals of Phobias

Fundamentals of Phobias:
Acquisition, Maintenance
and Clinical Practice - A
View from Learned
Conditioning
Introduction to Psychology
Cyprus University
Department of Psychology
2013
Raúl de las Mulas Fernández
Index
I Introduction
II Framework
2.1 Classical Conditioning: Pavlov
2.2 Rescorla & Wagner Theory
2.3 Basic Principles of Classical Conditioning
III Definition of Phobia
IV Acquisition of Phobias
V Maintenance of Phobias
VI Classical fear toward Functional Neuroimaging
VII Coping with phobias
7.1 Live exhibition
7.2 Counterconditioning and Systematic Desensitization
7.3 Flooding
VIII Conclusions
2
I. Introduction
Classical Conditioning has been one of the greatest discoveries with various
applications in Psychology. Although Classical conditioning is based on reflex
associations, this mechanism of learning can explain a long variety of behaviours.
Between these behaviours we can find in Classical conditioning the explanation for
clinic conditions such as dependency to drugs or the acquisition of Phobias.
In this paper we are going to analyze the role of Classical Conditioning and other
phenomena of Conditioning related with phobias. We will revise the mechanism that
explains the acquisition and maintenance of these phobias, and the techniques that have
been developed for removing it.
We will begin with introducing the basic principles about Classical Conditioning
based in the Pavlov's discoveries. We will continue with the development of these
principles based on the Rescorla and Wagner Theory before we finally analyze in depth
the mechanisms that are involved in the acquisition, maintenance and extinction of these
conditions.
We will show some assumptions of practical cases to illustrate these processes that
take place when someone acquires and maintains a phobia.
Finally, we will discuss some techniques used in clinical practice, which are
grounded in learning conditioning, specifically in the frequent avoidance response
shown by people with specific fears to some stimulus.
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II. Framework
2.1 Principles of Classical Conditioning
The discovery of Classical Conditioning was possible by Pavlov's research. This
Russian physiologist was the first scientist that showed the Classical Conditioning while
he studied the salivary response in dogs. He tried to measure the salivary response in
dogs when he administered food to them. He noticed that dogs began to produce a kind
of anticipatory salivary response before any food was presented (Gilbert, Wegner and
Schacter , 2009).
With this discovery, Pavlov began to study this kind of response and released the
four basic elements of Classical Conditioning (A view of the description of this
procedure
can
be
found
in
the
following
internet
link:
http://www.youtube.com/watch?v=hhqumfpxuzI )*
In short, Classical Conditioning is a type of learning that is acquired when a
neutral stimulus evokes a response after being paired with a stimulus that
naturally evokes a response (Gilbert, Wegner and Schacter, 2009).
The stimulus that naturally evokes a response was called by Pavlov "Unconditioned
Stimulus". Examples of this type of stimulus are for example a harmful stimulus such as
electric shock, that evokes defensive responses like removing the hand from the pain
focus. This response was called "Unconditioned Response". (Vila et al., 2009).
Electric shock in hand (US) ------------------------------> Remove the Hand (UR)
When a neutral stimulus is paired with the Unconditioned Stimulus and evokes a
response it is called "Conditioned Stimulus". The response that evokes is the
"Conditioned Response" and this response generally resembles or is the same as the
response that evokes the "Unconditioned Stimulus" (Gilbert, Wegner and Schacter,
2009).
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As illustration we can think in the following scheme:
Sound (CS) - Electric Shock (US)
Remove the hand (UR)
Remove the hand or fear to the sound (CR)
After some trials, the sound that precedes the Electric shock produces one response.
Be aware that the sound in the beginning must be neutral stimulus that does not evoke a
response.
These are the basic principles that Pavlov presented, but in this scheme it is not
relevant any element related with some cognitive elements. We have to investigate the
development of Classical Conditioning. For that, in the next paragraph we are going to
show the main results derived from Rescorla and Wagner Theory.
2.2 Rescorla and Wagner Theory
The Rescorla and Wagner model does not require an interpretation of learning as
cognitive, which is expressed associative strength. However, the Rescorla-Wagner
model allows to design the classical conditioning from a simple vision reflecting,
molecular, smooth and contiguous to a more complex conceptualization: Cognitive,
molecular, skeletal and contingent (Perez-Acosta, 2001)
Rescorla demonstrated in 1968 that the contingency of a CS–US pairing, and not
just the number of times this pairing occurs, is important in conditioning (Trimmer et
al., 2012). Rescorla and Wagner assume that associative strength is due to the surprising
of the unconditioned stimulus.
They showed a rule that was related not only with the number of trials. We can
consider a learning situation that involves two stimuli, a US and a CS, where the value
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of the US is fixed and known. We denote the associative strength of the CS and US by
"V", which may for instance, represent the probability of the US following CS. The
Rescorla Wagner Rule for updating the associative strength from "V-old" to "V - new"
following a single trial is:
V new = V old + alfa x Beta ( Lamda - V old)
Where Lamda is the value of the reward received on a particular trial, Alfa is the
learning rate parameter associated with the CS, and Beta is the learning rate parameter
associated with the US. The learning rate parameters, 0 < Alfa, Beta < 1, are often also
referred to as the salience of the stimuli (Dickinson ,1980 ; cited by Trimmer et al,
2012) .
In short, the theory of Rescorla and Wagner indicates that for a particular trial,
the increase of learning is a constant fraction of what they have learned through
previous trial.
2.3 Basic Principles
In Classical Conditioning we also have to take into account some basic principles
that occur in the learning of classic conditioning. Some of the most important among
these, which are also related to this paper’s subject of phobias, are the following:
- Stimuli Generalization: Refers to the ability of one stimulus to elicit a response
because it shares some properties with a different stimulus. The degree of stimulus
generalization observed is thought to be a direct function of the similarity between the
CS used in training and the test stimuli (Barnet, Grahame and Miller, 1995)
- Discrimination: Is opposite to Generalization. The learning response is produced by a
particular stimulus and not for others similar. For instance: The health staff
distinguishes between the sound of police sirens and ambulance sirens.
- Extinction: Decrease in strength or frequency of one acquired response, due to the
interruption of the paired between US and CS.
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- Spontaneous recovery: Recurrence of an extinguished conditioned response after a
period of time without extra training.
These principles frequently act in the different phobias as we are going to see in the
next lines.
III. Definition of Phobia
According to DSM-IV-TR, Specific phobia (SP) is an anxiety disorder classification
that represents unreasonable or irrational fear related to a specific object or
situation. At that time, five types of SP were listed: blood/injection/injury (B-I-I),
animal, natural environment, situational, and other (LeBeau et al., 2010). In concrete we
can see the definition that DSM - IV -R realized in the next table.
Table 1. DSM-IV-TR Criteria of Specific Phobia
A: Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a
specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)
B: Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which
may take the form of a situationally bound or situationally predisposed panic attack. Note: In children,
the anxiety may be expressed by crying, tantrums, freezing, or clinging
C: The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may
be absent
D: The phobic situation(s) is avoided or else is endured with intense anxiety or distress
E: The avoidance, anxious anticipation or distress in the feared situation(s) interferes significantly with
the person’s normal routine, occupational (or academic functioning), or social activities or relationships,
or there is marked distress about having the phobia
F: In individuals under 18 years of age, the duration is at least six months
G: The anxiety, panic attacks, or phobic avoidance associated with the specific object or situation are not
better accounted for by another mental disorder, such as obsessive–compulsive disorder (e.g., fear of dirt
in someone with an obsession about contamination), posttraumatic stress disorder (e.g., avoidance of
stimuli associated with a severe stressor), separation anxiety disorder (e.g., avoidance of school), social
phobia (e.g., avoidance of social situations because of fear of embarrassment), panic disorder with
agoraphobia, or agoraphobia without history of panic disorder
Note: DSM -IV - TR Criteria for Specific Phobias (Lebeau 2010)
Depending on the type of the specific phobia that a person develops, we apply
different methods. For instance, the blood/Injection/Injury phobia has a particular and
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specific pattern and for that, we cannot apply the same method to all phobias even if
they share elements. However, as we will see, there are some treatments that can be
used in almost all phobias.
We have to know that the clinical phobia is different to the term used commonly by
people. Almost all people have fear to some particular situation or object, but this does
not mean that all of them hold the clinical phobia condition. It is important to know that
the fear has to evoke interferences significantly in the person's life, according to the
E criteria of DSM.
IV. Acquisition of Phobias according to Classical Conditioning
The acquisition of phobias according to Classical Conditioning is relatively easy to
understand. The easiest example is when the fear object is present as a physical
association. We can mention the most popular experiment in this way: The Watson's
study with the little Albert (For reading more about this experiment you can consult
Gilbert, Wegner and Schacter , 2009 ; Psychology pp: 218-219) The process that takes
place is the association of a Neutral Stimulus with the Unconditioned Stimulus.
At the root of all anxiety disorders the role played by external factors (such as
family environment, educational style...) as well as internal factors (such as
temperament or personality) is important. External and internal factors are interrelated
and predispose to a greater or lesser vulnerability of each person to develop these
phobias.
Not all stimuli are equally likely to acquire phobic properties. This can be
explained by biological preparation: more easily acquired fear to stimuli that are
phylogenetically represented as a threat to the survival of the species, this threat can be
for attacking or spreading a disease (the latter include those animals spiders,
cockroaches, rats or mice that in addition to possible fear, provoke disgust) (Bados,
2005)
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One version of the theory originated in the important work of Mowrer. “The
position here taken is that anxiety is a learned response, occurring to signals
(conditioned stimuli) that are premonitory of (i.e., have in the past been followed by
situations of injury or pain [unconditioned stimuli]” (Mowrer, 1939, p. 565; cited by
Rachman, 1991). It is postulated that fears are acquired by a process of conditioning.
“Neurotic reactions, like all others, are learned reactions and must obey the laws of
learning,” (original emphasis, Eysenck, 1960 p. 5). Neutral stimuli that are associated
with a pain-producing or fear-producing state of affairs develop fearful qualities; they
become conditioned fear stimuli. The strength of the fear is determined by the number
of repetitions of the association between the pain/fear experienced and the stimuli, and
by the intensity of the fear or pain experienced in the presence of the stimuli (Rachman,
1991).
We are going to introduce one example of this process. We are going to imagine a
person with fear to wasps. Also we will imagine the origin of this fear, probably a sting
of this insect. (Be aware that we will see later that it is not necessary that the origin of
the fear is the sting). Now we are going to use a naming from the classical conditioning
nomenclature.
US = Sting
CS = Wasp
UR = Pain
CR = Avoid pain (Fear)
CS (Wasp) - US (Sting) -------------------------------------------> UR (Pain)
CR (Avoid wasp, Fear)
It is relatively easy to understand, however, as we remember the Rescorla and
Wagner work, that it is not only this success that explains the acquisition of the phobia.
It depends on other factors such as the intensity of this situation and overcoat depend of
the surprising of the episode.
9
Also the fear may be developed from other types of learning. But these types of
learning interact with Classic Conditioning.
Direct traumatic conditioning experiences were neither necessary nor sufficient for
the development of fears and phobias (Mineka and Oehlberg, 2008)
Rachman (1977) outlined a “three pathways” model of acquisition. Whilst one route
was via normal conditioning with direct experiences with trauma, the other two
represented vicarious learning consisting of the transmission of information and
observational learning (Davey, 1992)
In Vicarious Learning the person acquires fear to the situation or object of fear after
watching how it acts. In our example for instance, the person watches how the wasp
stings to his/her cousin.
In this case the scheme will be the following:
US = Sting
CS = Watch how wasp stings his/her cousin
UR = Startle reflex
CR = Fear
CS ( Watch the episode) - US (Sting) -----------------------------> UR (Startle reflex)
CR (Fear or startle reflex)
In animals, it is clear that learning of aversive reactions and avoidance responses can
be facilitated by first observing a specific experiencing of the contingencies (e.g., Del
Russo, 1975; Zentall 50 G. C. L. Davey & Hogan, 1976; Lore, Blanc, & Suedfeld,
1971; cited by Davey, 1992), and the work of Mineka and her colleagues has
demonstrated that observational learning of fear responses in monkeys is a reliable and
robust phenomenon (Davey, 1992).
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And this is not all; the wasp’s presence is not even necessary for developing fear to
it. This is that we call Verbal Conditioning, that is, the person receives verbal
information about the fear object. For instance the mother always says: "Be careful with
wasps that when they sting you, you feel pain".
Obviously this type of Conditioning has cognitive components, since the image is
created by language information. For that the development of fear in this way is only
applicable in humans.
In this case, in the above scheme we only have to change the meaning of CS by the
mother notice about wasps.
The strongest and most systematic evidence that the fear can be conditioned was
drawn from a multitude of experiments on laboratory animals. Evidently, it is easy to
generate fear reactions in animals by exposing them to a conjunction of neutral and
aversive stimuli, usually electric shock. The acquired fear reactions (usually inferred
from the emergence of avoidance behaviour, physiological disturbances, and disruptive
behaviour, or by some combination of these three indexes) can be produced readily by
employing conventional conditioning procedures. There is little doubt about the facility
with which fear reactions can be conditioned, at least in animals that are tested under
laboratory constraints (Rachman, 1991).
Another procedure related with the acquirement of phobias is associated with two
processes that were explained before. These are the Generalization and Discrimination.
A lot of times people that suffer a particular phobia tend to generalize the fear object
to other situations and objects that have similar compounds. For instance, following our
example, the fear to wasps can be widespread to others insects that share same elements
as wing, sting etc. So, our subject can develop fear also to bees, bumblebees etc.
The same occurs with other fears, such as the fear of flying. The person can develop
fear to other vehicles different to the plane, as helicopters, ship or even cars. So, the fear
can be widespread to accidents rather than planes.
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The opposite phenomenon to generalization is the Discrimination and it can too
occur. When this phenomenon occurs the person tends to discriminate between similar
stimuli and detect only one particular stimulus. In this way the person that has fear to
wasps can distinguish between them and bees. For example, is usual that people that
with a fear to wasps don't develop fear to bees because they learnt that bees only sting if
the situation for them is very dangerous. The same occurs in the flying-fear example. A
person can distinguish between situations such as when the weather for flying is
adverse.
Finally, there is another process that can be widespread to others situations. We refer
to second order conditioning or higher conditioning. In the second order conditioning
there exist three phases.
According to Pavlov (1927), in the first training phase a conditioned stimulus (CS1)
is followed by an unconditioned stimulus (US). In the second phase, a second order
conditioned stimulus (CS2) is presented along with CS1. Finally, in the test phase, CS2
is presented alone to the subjects while their responses are recorded. The results have
commonly shown that CS2 evokes the same conditioned response (CR) as does CS1,
even though CS2 was never directly paired with the US (Jara, Maldonado & Vila,
2006).
For instance, the person who has fear to wasps can associate pools or mountains to
wasps, because it is in these contexts that this kind of insect usually appears.
The first conditioning will be:
US = Sting
CS = Wasp
UR = Pain
CR = Avoid pain (Fear)
CS (Wasp) - US (Sting) -------------------------------------------> UR (Pain)
CR (Avoid wasp, Fear)
And the second conditioning will be:
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Stimulus (2) [Pools] -- CS(1) [Presence of wasps]
CS(1) [Presence of wasps] -- US [Sting of wasps]
V. Maintenance of Phobias.
The process of maintenance of phobias is easy to understand too. In short, the reason
why people maintain their fears is that they do not allow disconfirming the association.
So, the expectancy of anxiety provokes that the subject avoids this situation and hence,
the subject does not have the possibility for disconfirming her/his fear.
In this field we have to take into account that the conditioning that works is not the
classical conditioning. In this way, the process that occurs is the avoidance that is
negatively reinforced " because it prevents anxiety and prevents the occurrence of its
start-aversive consequences (crash, bite, shock-les automobiles, drowning, falling,
losing control, having a panic attack, fainting)" (Bados, 2005). Moreover, the phobia
can also be positively reinforced (attention, care, satisfaction of dependency needs) and
that also contributes to maintaining this condition (Bados, 2005). The negatively
reinforced means that the behaviour (avoid) will increase because the contingency is
negative (disappears something - the phobic object). Positively reinforced means that
the behaviour increases also but the contingency is positive that is, there appears
something like attention to the person.
According to our example, the subject that has fear to wasps will try to avoid the
situations where wasps are possible to appear. So, she/fe cannot disconfirm that the
presence of wasps may end without their sting to her/him.
If the feared situations are unavoidable, it is possible an attentional bias or
hypervigilance toward the fear stimulus appears, which can facilitate the escape of the
threat. However, the data are not very clear with the existence of this bias (Antony &
Barlow, 2002; cited by Bados, 2005).
Also the subject can keep the expectations of a certain threat due to cognitive errors
such as wrongly attributed to luck or ignore the information contrary to what one
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believes. For example, the person who has fear of flying and has to travel in plane duly
can attribute arriving to her/his destination safe due to the luck.
Finally, new episodes of occurrence of aversive consequences in the feared situation
or observation or knowledge of them in other help maintain the phobic (Bados 2005).
VI. Classical fear toward Functional Neuroimaging
Fear conditioning has proven to be an extremely robust, rapid, and precise
experimental approach for studying the neurobiological substrates of fear. Büchel et al
(2000) review compared event-related fear conditioning studies to block-design studies
and positron emission tomography (PET) studies. This review was one of the first to
identify a common core network for human aversive conditioning, including the
amygdala and anterior cingulate cortex (ACC) (Sehlmeyer et al, 2009).
The Büchel's studies were the following, using PET:
"Subjects were scanned during an initial habituation phase during
which the visual stimulus (a video-tape showing various snakes) was
presented alone. During the following acquisition phase, the subjects
were conditioned to the snake video by pairing it to electric shocks.
Acquisition phases were not scanned. During a final extinction phase,
snake videos were presented again but unpaired (i.e. identical to the
habituation phase). The comparison of interest was between the
habituation and the extinction phase, in which learning had taken
place. The analysis of autonomic responses (i.e. SCR) confirmed that
conditioning had occurred: subcortical activations were seen in the
thalamus,
hypothalamus
and
the
mid-brain,
and
cortical
activations were observed in the cingulate gyrus, the premotor
cortex and bilateral parietal cortices. Cortical activations were
mainly attributed to attentional mechanisms related to the salience of
visual stimuli after conditioning" (Dolan & Büchel, 2000)."
The most interesting finding was the absence of Amygdala activation.
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In recent studies using PET, the authors want compared the activation
when subjects were conditioned with a CS aversive (CS+) and a CS that was
never followed by the US (CS-).
Comparison of CS+ versus CS– showed activation in the pulvinar and the anterolateral thalamus. In a post-hoc analysis, regions in the brain that correlated
significantly with the response in the pulvinar, as highlighted in the main analysis, were
identified. Regions showing a significant temporal correlation with the right pulvinar
included the right amygdala, the basal forebrain and bilateral fusiform gyri (Dolan
& Büchel, 2000).
All classical conditioning paradigms described so far presented a "CS+" (aversive)
overtly. However, this overt presentation is not a necessity for learning, as conditioned
responses can also be achieved if a "CS" is presented outside of awareness. The
technique is called "backward masking". This masked emotional learning paradigm was
employed and showed that the amygdala was only activated during the "CS+" scans
but not during the "CS–" scans. The authors further observed an interesting
hemispheric difference: the right amygdala was activated to a greater extent than the left
amygdala if the "CS+" was presented out of awareness, whereas this was reverse when
the "CS+" was presented consciously. (Dolan & Büchel, 2000).
These techniques have been important for detecting the areas that are involved when
the fear is acquired by classic conditioning. The studies in this way show two
neuropsychological perspectives.
One view suggests a role for medial temporal lobe structures in modulating or
enabling associative changes in cortex. The hypothesis is that brain systems that
mediate learning, in which the amygdala plays a central role, do so by enabling or
permitting associative plasticity that encodes sensory contingencies that are being
acquired (Dolan & Büchel, 2000).
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In the alternative view, the amygdala is regarded as a rapid subcortical information
processing unit that is continuously involved in the processing of the CS (and US) in
aversive classical conditioning (Dolan & Büchel 2000).
VII. Coping with phobias
As we said previously, from the clinical perspective, we need to find the best
treatment for the patient. Neither is there only one treatment for coping with phobias,
nor are these treatments one hundred percent effective. We are going to explain some of
them that are used usually by clinicians.
7.1 Live Exhibition
Before beginning with the patient, the latter has been informed about why we are
going to use this technique that is the justification of the technique. Therefore, we
have to inform to patient that this technique allows to:
- Decrease the association between the internal stimuli/fear situation with the anxiety
- Check that the anticipated negative consequences do not occur.
- Learn to manage the anxiety and panic. (Bados, 2009)
We have to inform equally, that the exposition will be gradual (Increase in
difficulty), the velocity of the process will be agreed together between patient and
clinician, the patient will not be obligated to do something that she/he does not want,
and the situations that in that moment seem difficult in the future will be better (Bados,
2009)
Graduation
The exposition should be graduated according to this rule: from the situations that
the patient feels less apprehension to situations that produce more fear to her/him.
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The graduation rate depends on what the customer is willing to tolerate, their
medical and psychological conditions, the time available and the speed of habituation
(Bados,2009)
Treatment characteristics also depend on the type of grading to do. Low graded
treatment tends to reduce patient’s acceptance and to encourage more dropouts and also
it is less suitable for children and people with major medical problems (such as people
who have had myocardial infarction). On the other hand, the graded exposures are
related to slower progress and abandonment by bluntness of the patient.
Hierarchy of the exposition
The patient has to order the situations hierarchy, from the situations that produce
more anxiety, to the situations that produce less anxiety.
The clinician has to facilitate the initiative of the patient. The patient must include all
fear situations, and if they are too many, she/he must include a representative sample of
them. Also, the situations must be significant in the diary life of the client and
interfering in her/his life.
Situations must be described with sufficient specificity in order to make a good
hierarchy and thereby maintain the control about the generated anxiety of the client. The
exposition must be conducted in different contexts and with a diverse range of stimuli in
order to facilitate the generalization and prevent the return of the fear (Antony &
Barlow 2002, cited by Bados 2009).
The number of situations or steps are variable, although usually contain between 10
or 20 situations. The clinician and the patient can agree these situations from the
beginning but these are usually provisional. It is better to make partials hierarchies
while the intervention takes place.
17
Duration of the exposition
In general, this technique has better overall if the exposition is continuous and
prolonged. The patient must try to remain in the situation until she/he feels that the
anxiety disappears or decreases.
Depending on the type of phobia, the duration when facing the situation must be
different. For instance, if the situations have short duration (such as situations that
involve entry in an elevator), the situations have to be repeated several times. The
number of repetitions depends on the levels of anxiety that the patient feels in it. If it is
possible, it is recommended that the patient copes with the fear situation between 1-2
hours per day.
When do we know that the anxiety when the decreased? The significant reduction
takes place when the anxiety decreases at least the 50% related with the maximum that
the patient felt in that situation or the anxiety reduction is 0 or remote (0-2 in a scale
with 8 as maximum).
On the other hand, we have other perspective that takes into account habituation
between sessions (inter-sessions) instead of into-sessions. In this perspective the patient
has to remain in the fear situation until she/he learns that the expected consequences do
not occur, instead of remaining until the anxiety is lower. In this way, although the
patient keeps the anxiety in one session, in the next sessions, it will go down.
Finally, other alternative perspectives say that, the duration of the technique
depends of the control degree that the patient feels. For that, the fear situation has to be
repeated until the patient feels in control of it.
Exposure speed
According to Yucksen et al. (1984), it is not necessary that the technique produces a
maximum habituation to one item of the hierarchy before following with the next.
However, according to the studies of Marshall (1985), it is better to keep the exposition
until the anxiety disappeared.
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Many patients are satisfied when facing good one kind of situation once and they
believe that this situation has passed and do not need more trials. However it is normal
that this behaviour masks the fear of them. For that, the patient has to pass the situation
repeatedly, because if they do not feel fear it is not important to pass from the same
situation again.
Implications of treatment
Apparently the patients that pay more attention in the task, are likely to cope better
with the phobia in comparison to the patients that do not pay attention in it. However,
the distraction effects studies are controversy. Telch et al. (2004) find that it is not the
distraction "per se" the most important factor that interfering with the fear reduction. It
is the level of the distracting task reduce the attentional resources available for the
cognitive processing (cited by Baros, 2009).
Also, the results of the effectiveness of the treatment depend of the personality.
Patients are different for example in copying styles. Muris et al. (1993) show that in
spider-phobic people, the seeker’s style relapsed more than the people with avoid style
(cited by Baros, 2009)
Other factors to take into account in this technique are the following: the
participation of the clinician, the family and friend support, panic attack during the
expositions, relation between clinician and patient, expectations of the patient, the autoexposition in absence of the clinician, drugs consumption etc.
7.2 Counter-conditioning and Desensitization
Counter conditioning is teaching a different task or behaviour than the one that was
previously occurring in a situation. In the field of phobias, the example is relatively
simple. We pretend to remove the phobia, for that, we would try to teach to the patients
the opposite response of the anxiety. In short, the counter-conditioning would consist in
substituting one learned fear response by another opposite as the relaxation response.
19
The Desensitization "as a reciprocal inhibition" was a concept proposed by Wolpe
based on Hull's (1943) drive-reduction theory of classical conditioning, a fatigue theory
of extinction (Conditioned inhibition), and Sherrington's (1906) concept of reciprocal
inhibition, whereby the evocation of one reflex suppresses the evocation of other
reflexes (Davison, 1968).
In words of Wolpe (1958):
"If a response antagonistic to anxiety can be made to occur in
the presence of anxiety-evoking stimuli so that it is accompanied
by a complete or partial suppression of the anxiety responses, the
bond between these stimuli and the anxiety responses will be
weakened (p. 71)"
The central idea in this technique is the previously exposed and for that, we have to
know about relaxation techniques and how to teach them to our patients. Two of the most
widely used in psychology are the "Autogenous training" of Schultz and the "Progressive
muscular relaxation" of Jacobson.
The utility of relaxation is that it leads to the achievement of a reduction state of
general activation of the body, so that this benefit is both subjective, since it is
pleasurable, as well as the own physical and psychological health (Chóliz, 1995).
In Autogenous training of Schultz, the essential elements of the induction technique
autogenic state are: Passive concentration, mental repetition of formulas welds, mental
contact, reduction of the stimulation (González de Rivera, 1980) [For a detailed view of
this technique consult the complete article].
The Progressive muscular relaxation of Jacobson consists in the relaxation of the muscles
that compound the body. Jacobson teaches us to relax the muscles voluntarily as a means
to achieve a deep state of inner calm that occurs when unnecessary stress leaves us.
Freedom from physical stress is the essential step prior to experience the feeling of
calmness
voluntary
(For
a
detailed
view
of
this
technique
consult
20
http://www.psicologotarragona.com/material/articulos/psicologo.pdf). Both techniques
can be implemented and used together.
So, the hierarchy to follow in this technique is relatively simple:
First we have to provide training in some relaxation technique to the patient. The
technique will be chosen in function of the technique that can decrease arousal levels of
the patient effectively. Then, once the patient obtains a good relaxation, we have to
expose to the stimulus phobic following the hierarchy that we made previously.
Frequently these stimuli are showed in imagination. We have to be aware that the stimuli,
in fact, do not confirm the fear that the patient feels. Then progressively, we have to
expose the following phobic stimuli when the patient completely pass the previous
stimuli and does not show the fear toward it.
7.3 Flooding
This technique is based in the avoidance response. The avoidance response is a
learning response as a consequence of instrumental conditioning. From the practical point
of view, methods of extinguishing avoidance responses can serve as a model for
developing techniques within the Behavior Therapy, which aimed at the elimination of
avoidance behavior.
According to Mowrer, the avoidance response is acquired also by Classic
Conditioning. This perspective establishes the combination between Instrumental and
classic conditioning that determine the avoidance learning. According to this theory,
Classical conditioning happens as a result of fear or drive to the feared stimulus signal.
Then acts through the conditioning instrumental negative reinforcement in which the
result of avoiding the feared stimulus reduces an urge acquired (Perez-Acosta, 2005).
Baum (1976) proposed the term inundation (flooding) to denote a set of techniques of
extinction of avoidance responses (c.f. Perez-Acosta, 2005).
Although this author proposed three types of flooding, Polin (1959) later called
flooding only to the following procedure: to allow the experimental subject performing
the avoidance response as often as he/she wants, but the subject is not able to eliminate
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the aversive conditioned stimuli during the acquisition of the behavior preceded the
administration of a noxious stimulus (Fernández Castro, 1979).
In summary, flooding is to break the relationship between the response contingency
avoidance and termination of the conditioned stimulus. This also applies if they are used
feedback stimulus, which is any stimulus that is delivered contingent on the execution of
an avoidance response and, therefore, are associated with the omission of the aversive
stimulus.
But this technique showed to be effective in some cases and ineffective in other cases.
For instance, It has been found repeatedly, but not on a regular basis by classical aversive
conditioning that the presentation of conditioned stimulus without the unconditioned,
rather than lead to the extinction of conditioned responses leads to its increase (Eysenck,
1968; Woods , 1974; Riccio and Silvestri, 1970; cited by Fernández-Castro, 1979).
Summarizing this technique:
- allows facilitating the extinction of avoidance behavior.
- affects different avoidance responses and conditioned fear.
- greater duration of flooding greater facilitation of extinction.
- if we administer inhibitors of conditioned fear increases the effectiveness of flooding.
However, there are data supporting that frightening stimuli act in the same way
(Fernández-Castro, 1979).
This technique can be used in two ways. The exposition can be in imagination or, in
live. It is specially indicated for:
Agoraphobia, social phobia, Post traumatic stress disorder and obsessive-compulsive
disorder. Also applicable to internal stimuli that cause fear, such as fast heartbeat in the
case of panic disorder.
For applying the technique, the patient has to be exposed in form prolongued to the
aversive stimuli (almost always in imagination). The clinician has to use four types of
stimulus keys: External stimuli, internal stimuli informed by the patient, internal
hypothesized by the clinician and hypothesized stimuli based on psychoanalitic theory.
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Finally, this technique is frequently more effective if the anxiety response is maximized
(high emotional descriptions).
The procediment is the following:
1. Explanation and Justification of the technique
2. Development of key stimulus: using the patient develops a list of key external and
internal self - report stimuli contingent. In addition to the key hypothesized by the
therapist and psychoanalytic theories.
3. Practice imagination with neutral scenes.
4. Sessions of implosion: the scenes are keeped while there is evidence of external signs
that evoke emotional arousal. Then we have to continue until the emotional responses are
extinguished. around 45 - 60 minutes per session sufficient.
5. Practice sessions at home by the patient.
VIII. Conclusions
The role that fear plays in human behavior has an adaptive value for the species.
However, when this fear becomes excessive and interferes with a person's life, this fear
becomes maladaptive. As we have seen, some theories posit that biological factors come
into play, so for example we would be more likely to be afraid of spiders, snakes,
darkness etc. However, experiential factors also come to stimuli that at one time served as
a signal to be feared. So, the acquisition by conditioning to these signals also plays an
important role. These factors don’t jsut explain the acquisition of fear. A component that
distinguishes us as human species is the language and there are many fears that we
acquire in this way. As we have seen, it can be conditioned to fear us and anticipatory
images and be conditioned by the information that others provide. Therefore, we must
also take into account social factors and even cultural ones because over the wide range
of cultures there are fears more pronounced cross-culturally.
The maintenance of these fears is, in most cases, due to avoidance responses to the
feared stimuli, and the person with an irrational fear cannot disconfirm these events to
stay out of the feared stimulus. Therefore, from the psychology, techniques derived are
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justified in exposing the person to the feared stimulus, either in imagination or in vivo,
for disconfirming them. From these views, we have to take into account other factors,
because depending on the specific fear that the person possesses or the type of
physiological and behavioral reactions it arouses, we must employ the most appropriate
technique. Thus, depending on these factors will choose gradual exposure to fear or
direct techniques such as flooding.
Phobias are a relatively common phenomenon. So we need to develop principles and
practices for an increasingly effective treatment, for instance, through the new
technologies.
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