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What is fear? What is anxiety?
Fear - unpleasant feeling of anxiety or
apprehension caused by the presence or
anticipation of danger
Anxiety feeling of worry: nervousness or agitation, often
about something that is going to happen
PSYCHIATRY extreme apprehension: a medical
condition marked by intense apprehension or fear
of real or imagined danger
When does anxiety become a problem?
All people experience anxiety at some time.
It is a normal element of human existence.
However, anxiety can become a major problem
with disturbing consequences.
What axis in DSM-IV-TR do anxiety disorders come
under? (see textbook if you have forgotten)
Anxiety disorders
Come under Axis 1 and are characterised by
extreme apprehension, fear, stress and unease.
5 main types of anxiety disorder
1. Generalised
2. Posttraumatic
5. Phobic
3. Panic
What is a phobia?
A phobia is a persistent, irrational and intense
fear of a particular object or event.
persistent - existing for an unpleasantly long
irrational - lacking in reason or logic
intense - extreme in a way that can be felt
What cause simple phobias?
After many years of extensive research into the origin
and maintenance of simple phobias, scientists came to
an important conclusion - there is no simple explanation
Main factors are:
Genetic tendencies
Brain chemistry
Subcategories of phobias
Social Phobia
• Fear of other people
• Fear of social situation
• Fear of leaving a familiar
Simple phobia
or Specific
• One specific object/event
• e.g. – fear of heights
Click here for the four main types
of simple phobias
Four main types of simple phobia:
Natural Environment
Situation Phobias
Blood - injection
-injury phobia
Symptoms of phobic anxiety
elevated heart rate & blood pressure
tremor (shaking in hands)
palpitations (abnormally fast heartbeats that a
person is aware of)
shortness of breath
Fear of clowns- symptoms
Watch the following You Tube video that explains
the symptoms by someone suffering from a simple
At what age to phobias start?
Age of onset of simple phobias:
12 years
20 years
Before 20 years
Late adolescence early
Most simple phobias first appear at anytime, but
particularly during adolescence.
A panic attack is the unexpected onset of intense
anxiety that can last for a few minutes or up to an hour
or so.
Sufferers experience:
 Great discomfort
 Shortness of breath or tight in the chest
 Become disorientated
 Often fear the panic attack will happen again and
lead to total loss of control or even death
Not classified as a separate disorder in the DSM-IV-TR.
Panic attacks are a symptom in a number of anxiety
disorders described in the DSM
e.g. Panic disorder, specific phobia, social phobia,
PTSD (post traumatic stress disorder)
DSM diagnoses panic attacks when 4 or more symptoms
develop suddenly and reach a peak within 10 minutes.
Symptoms such as: sweating, trembling, chest pain,
feeling of choking, dizziness, feeling lightheaded or
faint, depersonalisation (detached from oneself), fear
of dying, chills or hot flushes, fear of losing control or
going “crazy”, nausea, abdominal distress etc.
Biological factors & phobias
GABA- found
in 40% of all
and inherited
• flight –or-flight response will occur when
a person is frightened or highly stressed
•Low levels of the neurotransmitter GABA
leads to higher levels of anxiety
• Anti-anxiety drugs that mimic GABA’s
inhibitory effects can help manage anxiety
• genetic vulnerability is expressed in a
person’s personality; people who are
nervous and apprehensive about objects
and events are more likely to develop
simple phobias and anxiety disorders
Research suggests we may inherit a predisposition or
“tendency” to develop an anxiety disorder.
Genetic research on identical twins – if one has an anxiety
disorder, the other is more likely to have an anxiety
This is not the case though with non-identical twins or other
Other biological factors that can contribute to specific
phobias and phobic reactions is the role of the stress
response and the brain’s neurochemistry (specifically the
neurotransmitter called GABA).
Psychological component of anxiety – apprehension,
worry, uneasiness
Physiological component underlies psychological
component of anxiety – like the physiological response
to stress – the fight-flight response is activated.
Heartrate up, heartbeat faster to speed up blood flow
and direct blood from where it is not needed to where
it is needed.
Adrenal hormones surge into bloodstream
Speed and depth of breathing increase
The symptom of feeling dizzy or even fainting are
thought to be due to initial increase in ANS arousal
followed by a sudden drop in blood pressure and
heart rate.
Phobic anxiety becomes problematic when the stress
response is triggered in the absence of any real
threat or danger (e.g. Objects or events that have
very little potential for actual harm).
A person with a specific phobia has their stress
response triggered by the perception of threat or
Because their perception of threat is unreasonable,
the level of anxiety tends to be excessive.
The stress response they experience is often very
severe and can persist at this high level for at least
as long as the exposure or anticipated exposure to
the phobic stimulus.
The role of Gamma-amino-butyric
Not enough Yo gaba gaba makes me anxious!
Gamma-amino butyric acid is the primary inhibitory
neurotransmitter in the CNS.
Inhibits postsynaptic neurons from firing – stops them
passing on the neural impulse
Gets in the synapse to block transmission
One of it’s role is it helps fine tune brain activity,
keeps neural transmission maintained at an optimal
or “best possible” level.
Without GABA, activation of postsynaptic neurons
might get out of control and spread throughout the
brain, causing seizures similar to those of epilepsy.
2nd most common neurotransmitter in the brain
Excitatory neurotransmitter in the CNS
Makes postsynaptic neurons more likely to pass on
the neural impulse (to “fire”)
Gets the post synaptic neuron excited so it requires
less stimulation to make it fire
Also plays a role in aiding learning and memory by
strengthening synaptic connections
Stop the message!
Get the message going!
GABA and Glutamate
The inhibitory effect of GABA counterbalances the
excitatory effect of glutamate and vice versa.
Therefore, they both have important roles in
regulating CNS arousal.
GABA is believed to play a role in anxiety.
GABA and anxiety
Lack of the neurotransmitter GABA might lead to over
stimulation, and thus heightened anxiety
Role of a group of drugs known as benzodiazepines in the
management of phobic anxiety provide evidence for the role
of GABA in anxiety.
Benzodiazepines – a class of drugs that ‘calm down’ neural
activity. Valiam, Xanax, Rohypnol, Serepax etc. commonly
referred to as “minor tranquillisers”
Benzodiazepines reduce physiological arousal and promote
relaxation, but induce drowsiness and are highly addictive.
All drugs are either Agonists – mimic the activity of a
Or Antagonists – inhibit the activity of a neurotransmitter
Inhibitory or agonist - a substance
that stops or slows a chemical
Benzodiazepines are GABA agonists.
They imitate
a substance
that and
stops or stimulate
slows a chemicalactivity at
Encarta® 2008. © 1993the site of reactionMicrosoft®
neuron where GABA
2007 Microsoft Corporation. All rights
is receivedreserved.
from a presynaptic neuron.
By doing this, benzodiazepines have inhibitory
effects on postsynaptic neurons and reduce
symptoms of anxiety by imitating GABA’s
inhibitory effects.
Ethyl alcohol (type people drink)
has similar
effects on GABA
a substance that stops or slows a chemical
reactionMicrosoft® Encarta® 2008. © 1993receptors
is why
alcohol is
Microsoft Corporation.
All rights
typically experienced as relaxing.
Antagonists inhibit a
neurotransmitter’s activity.
Agonist isa substance
the that
to antagonist.
stops or slows a chemical
reactionMicrosoft® Encarta® 2008. © 19932007 Microsoft Corporation. All rights
They reduce GABA function and
therefore produce anxiety
The GABA/Anxiety connection has
led researchers to hypothesise some
people develop anxiety because
they have
a dysfunctional GABA
a substance that stops or slows a chemical
reactionMicrosoft® Encarta® 2008. © 1993system –2007
of Allfailure
produce, release or receive the
correct amount of GABA that’s
needed to regulate neuronal
transmission in the brain.
Level of GABA in a person’s brain
may be affected by a wide range of
•Genetic inheritance
a substance that stops or slows a chemical
Encarta® 2008. © 19932007 Microsoft Corporation. All rights
• exposure
reserved. to prolonged stress
• exposure to environmental toxins
•Nutritional deficiencies (vitamin B6
and citric acid, and high caffeine
Proposals that GABA levels can be
increased “naturally” by:
• Drinking green tea
• Eating foods “high in GABA”
(e.g. Beans,
a substance
that stops orfoods,
slows a chemical
reactionMicrosoft® Encarta® 2008. © 1993seafoods
2007 Microsoft
All rights
• GABA supplements from health
food stores (although there is no
significant research evidence that shows
GABA supplements can penetrate the
“blood-brain barrier”.
The Blood-Brain Barrier is a physiological
mechanism that protects the brain (and
spinal cord) from undesirable toxins and
poisons in the blood that may cause harm.
a substance that stops or slows a chemical
reactionMicrosoft® Encarta® 2008. © 19932007 Microsoft Corporation. All rights
It consists of blood vessels that are semipermeable.
It allows some blood-borne chemicals to
pass through but not others.
Many drugs such as heroin and
cocaine can cross the blood-brain
barrier and affect neurotransmitter
a substance that stops or slows a chemical
reactionMicrosoft® Encarta® 2008. © 19932007 Microsoft Corporation. All rights
The GABA supplements may/may not
cross the blood-brain barrier and so
their effectiveness in managing
anxiety is unclear.
Caffeine induced anxiety disorder
Caffeine – the most widely consumed drug in the world
(coffee, tea, Coca Cola)
Low doses believed to improve sporting performance,
increase alertness and reduce fatigue, potentially lift mood.
Contains some anti-oxidants which have positive effects on
heart health.
Can also be useful for some types of headaches (e.g.
migraines) – in some cases reduced by caffeine.
Caffeine induced anxiety disorder
Some researchers though are increasingly concerned with
caffeine’s role in panic and other anxiety disorders.
Caffeine induced anxiety disorder has been added to the
One study found caffeine doses of 4 to 5 cups given to people
with panic disorder, nearly half of participants experienced a
reaction just like their panic attacks.
Symptoms can include appearing “wired”, overly talkative,
irritable, tachycardia (rapid heart rate), restlessness,
complaining about not being able to sleep well and having
energy “to burn”.
Caffeine induced anxiety disorder
Symptoms are believed to develop as caffeine inhibits
GABA release.
Too much caffeine is a direct consequence of having
high glutamate production without enough GABA to
counterbalance it in the brain.
Some people with anxiety symptoms are therefore
advised to avoid caffeine.
Theoretical approaches to explaining
psychological contributing factors
Psychodynamic model
Behavioural model: classical conditioning and
operant conditioning
Cognitive model
Psychodynamic model –
Is based on the work of Freud
(late 1800s)
States that the development of
all mental disorders including
phobias is due to unresolved
psychological conflicts that occur
in the unconscious part of the
mind, beneath ordinary conscious
awareness. that arise during the
phallic stage of a child’s
The conflicts originate in early
childhood experiences during
which our instinctive impulses
(“urges”) and society’s view of
what is “acceptable” behaviour
often clash.
If a person is unable to deal with
this conflict, their anxiety is
displaced to a situation or object
that is less relevant – e.g. in the
case of Hans a fear of horses.
Psychodynamic model –
Freud – the unconscious
is a storage place for
all information about
ourselves that is not
acceptable to the
conscious mind. (It is
NOT our memory
Freud – unconscious contains
all memories of experiences
that may be a source of
anxiety and thus very
difficult to bring into our
conscious minds.
Freud believed that the
unconscious thoughts and
feelings have a
considerable influence over
our conscious thoughts and
Psychodynamic model –
Following birth we each
progress through a series of
5 different psychosexual
Oral stage (0-2 years)
Anal stage (2-3 years)
Phallic stage (4-5 years)
Latency stage (6 – puberty)
Genital stage (puberty –
early adulthood)
“Sex” in Freud’s context meant
something “physically
pleasurable”, not specifically
sexual activity.
At each stage different parts
of the body become the focus
of our attention and pleasure.
Each stage has a crucial
developmental conflict that
must be satisfactorily resolved
in order to move to the next
•Phallic stage - in psychoanalytic
theory, relating to a stage of
psychosexual development during
which a young child's sexual
feelings are concentrated on the
•Oedipal & Electra complexes
Psychodynamic model –
An unresolved conflict can be“ a source of anxiety.
Freud described anxiety as an uncomfortable or
unpleasant psychological feeling that often arises
from the fear that our instincts will make us do
something we will be punished for.
We protect ourselves by using defence mechanisms.
Defence mechanisms
Defence mechanisms are
the conscious part of our
mind, called the “ego”
defending or protecting
itself against anxiety
arising from unresolved
internal conflicts.
Defence mechanisms
reduce anxiety by
denying, falsifying or
distorting reality at an
unconscious level and so
we have no need to feel
We are usually not
aware that we are using
defence mechanisms.
According to Freud a specific phobia he called anxiety
hysteria develops as a consequence of an unresolved
Oedipal complex.
The Oedipal Complex is a developmental conflict that
emerges during the phallic (third) stage of
psychosexual development (4-5 years).
It describes the unconscious, powerful, passionate love
and desire the male child has developed toward his
The term is now broadly used to apply to the desire of
either a male or female child to “possess” the opposite-sex
parent and “eliminate” the same-sex parent
The desire is unconscious so the child is not aware of it.
Soon after developing the desire the boy begins to fear
the father who is bigger and more powerful will become
aware of this and punish him by castration.
As a consequence the boy develops castration anxiety (a
fear he will be emasculated).
To successfully resolve the Oedipal Complex, the
male child uses the defence mechanism called
repression to prevent the socially unacceptable
desire and it’s accompanying anxiety from entering
conscious awareness.
It results in the boy identifying with his father. The
male child comes to act, think and feel as if he
were his father. He thinks if he is similar to his
father, then his father won’t punish him.
When repression doesn’t work, another type of
defence mechanism is attempted known as
Displacement involves directing feelings away from the
object or person that causes them to a substitute object
or person that is less threatening.
In this way the anxiety is redirected onto a seemingly
unimportant, irrelevant object or situation which
becomes the phobic stimulus.
The child can then deal with the unresolved conflict and
the anxiety by avoiding the phobic stimulus.
The phobic stimulus is related to and “symbolises”
the male child’s unconscious desire for his mother.
Thus, any feared object or situation associated with
specific phobia symbolises the source of an
unresolved Oedipal complex and triggers anxiety.
Read the case of “Little Hans” on pages 644 and
Behavioural Model: Classical and
Operant Conditioning
Behavioural model – phobias are learned
through experience and may be acquired,
maintained or modified by environmental
consequences such as rewards and punishment.
Classical conditioning processes play a role in the
acquisition (or development) of a simple phobia,
and operant conditioning processes play a role in
the persistence (or maintenance) of a simple
Behavioural Model: Classical and
Operant Conditioning
Focuses on observable
behaviours and
downplays cognition
Behaviours are learned
through classical
conditioning and
maintained through
operant conditioning.
Operant conditioning can
contribute to the
acquisition of a phobia by
rewarding when
comforting distress caused
by a phobia.
e.g. development of
dentist phobia
Think about ‘Little Albert’
– draw a similar diagram
to explain how his phobia
developed & was
Read examples on pages
646 and 647
Dentist Phobia
Classical Conditioning – phobia develops
 No Response
pain from injection
fear: due to pain from injection
visit to dentist
fear: due to pain from injection
 CR
fear: due to visit to dentist
Operant conditioning – phobia maintained
The avoidance of the unpleasant injection acts as a negative
reinforcer the strengthens the likely hood of that behaviour being
UCS– spider in sandpit
UCR– fear
NS– spiders
CS– spiders
CR – fear
Avoidance of spiders or spider related places, images
etc is negatively reinforcing, avoiding the bad stimulus.
This strengthens further avoidance behaviours
Cognitive Model
Emphasises the
influences of thought
is used to examine the
distorted thinking
process involved in the
Argues that anxious
individuals are more
likely to exaggerate
perceived threats,
making then more
likely to interpret some
situations, objects or
activities as more
dangerous than the
average person would
Cognitive Bias (“Cognitive Distortion”)
Key assumption –
people with phobias
have a cognitive bias
– a tendency to think
in a way that involves
errors and bad
judgement and faulty
decision making
Cognitive biases can
be habitual ways of
thinking and therefore
make someone more
prone to experiencing
fear and anxiety in
response to a phobic
There are several different types of cognitive bias:
Attentional bias
Memory bias
Interpretive bias
Catastrophic thinking
Attentional bias is the tendency to selectively attend to
threat-related stimuli rather than to neutral stimuli.
The person tends to pay more attention to “signs of
danger” (threatening information) in their environment
while ignoring “signs of safety” (non-threatening
E.g. A person with a fear of spiders may be the first or
only person in the room to notice a spider web.
They are hypervigilant always alert and constantly
looking around for something relevant to their phobia. It
is not helpful and maintains their symptoms.
Memory bias occurs when recall or recognition is
better for negative or threatening information than
for positive or neutral information.
E.G. A person with a phobia of horses may
remember the time they were chased by a horse but
not the other times when horses did not react to their
Interpretive bias (judgmental bias) is the tendency to
interpret or judge ambiguous stimuli and situations
in a threatening manner.
E.g. The fluff on the carpet as a spider
Catastrophic thinking is a type of negative thinking in
which the object or event is perceived as being far
more threatening, dangerous or insufferable than it
really is and will result in the worst possible outcome.
e.g. A dog phobia may cause a person with
catastrophic thinking to think the dog they encounter will
attack them and leave them with permanent facial
The person experiences heightened feelings of
helplessness and grossly underestimates their ability to
cope with the situation.
Socio-cultural contributing factors
3 most common contributing factors:
 Specific
environmental triggers
(developing a phobia after a direct negative
experience with an object or situation)
 Parental modelling
(observing and reproducing a parent’s fear of an
object or situation)
 Transmission of threat information
(exposure to negative or frightening information about
an object or situation).
Specific Environmental Triggers
Often an initial fear response to a specific environmental
trigger becomes a conditioned fear response through
classical conditioning processes and is produced whenever
the specific stimulus (or a generalised version) is
subsequently encountered.
Research indicates the more severe the initial trauma the
more likely a phobia will develop.
One encounter alone may be enough to produce and
maintain the fear response.
People are usually able to identify the particular traumatic
event that has caused the phobia.
Specific Environmental Triggers
A single traumatic experience does not explain the
fact that not all people who share the same
traumatic experience develop a phobia.
One reason given is each individual’s prior
Parental Modelling
Observational learning, or modelling, can lead to
development of phobias by observing another’s fearful
behaviour towards a particular object or situation.
Children most vulnerable to this as they do not have
knowledge or experience to know whether their
parents’ behaviour is appropriate or rational.
Not as common a pathway to phobias though as direct
Transmission of threat information
Transmission of threat information refers to the
delivery of information from parents, other family
members, peers, teachers, the media and other
secondary sources about the potential threat or
actual danger of a particular object or situation.
Sociocultural factors & phobias
Social and cultural factors can contribute to the type
and incidence (the rate of occurrence) of simple phobia.
e.g. A child whose parents suffer a phobia of moths is
more likely to develop the same or similar phobia.
Some phobias are culturally specific.
e.g. taijin kyofusho, a social phobia that appears almost
exclusively in Japan. This is a fear of offending or
harming others in social situations. It is different from a
traditional social phobia, in which the sufferer is afraid
of being personally embarrassed on humiliated.
Sociocultural factors & phobias: cont
Parental modelling can lead to the transmission of
threat information which is incorporated into a
child’s LTM and phobia can develop
i.e. children who are exposed to parents with
phobic responses are more likely to develop
comparable fears to similar stimuli
Treatments for simple phobias
1. Cognitive behaviour therapy (CBT):
- uses a combination of verbal and behaviour
modification to help people change their thinking
- focuses on the person to change negative thoughts
(flies can kill me) to more positive ones (flies are
unpleasant but they won’t hurt me if I am careful).
- person is encouraged to recognise that the
likelihood of their perceived events happening in
real life is very small.
- often combined with relaxation to treat a wide
range of phobias.
Treatments for simple phobias
Cognitive behaviour therapy (CBT):
Cognitive therapy deals with maladaptive thoughts and
beliefs, and behavioural therapy deals directly with
maladaptive behaviours such as avoidance and reduced
activity levels that can worsen or maintain a person’s
psychological problems.
In behaviour therapy, the habitual or reflexive ways of
responding that are maladaptive become extinguished and
new, more adaptive habits and reflexes are conditioned.
The emphasis on the cognitive or behavioural parts can vary,
depending upon the disorder and the person’s symptoms.
Treatments for simple phobias
Cognitive behaviour therapy (CBT):
CBT tends to be relatively short term, structured and focused on
the “here and now” type therapy. Functioning more effectively
in the present and the future is the focus.
Step 1
Person identifies their fear and anxiety related thoughts, as well
as any cognitive biases.
This can be done by asking questions of the person or may be
more direct and bluntly approached.
Step 2
Person is encouraged to look for evidence that supports their fear
cognitions and evidence that does not support them. Once these
thoughts are recognised as hypotheses not facts, they are open to
questioning and challenging.
Treatments for simple phobias
Cognitive behaviour therapy (CBT):
Step 3
Sometimes a person’s cognitive distortions result from a lack
of information or from inaccurate information.
So the client is encouraged to gather accurate information
about their phobic stimulus.
Once new evidence is evaluated, they are more able to
counter them with alternative more objective and useful
This new way of thinking will then lead to changes in their
feelings and behaviour, especially by reducing fear, anxiety
and avoidance.
Treatments for simple phobias
Cognitive behaviour therapy (CBT):
Step 4
The behavioural component of CBT can include engagement in
behavioural experiments (planned “hands on” activities the client
engages in between CBT sessions. They are designed to “test out”
the accuracy of the cognitive distortions.
Steps involved in setting up a behavioural experiment are:
Make a prediction
- Review existing evidence for and against the prediction
- Devise a specific experiment to test the validity of the prediction
- Note the results
- Draw conclusions
Read example on p. 661
Behavioural component of CBT
The behavioural component of CBT may also include
the use of:
 Systematic
 Flooding
Treatments for simple phobias
2. Systematic desensitisation
based on the idea that most anxiety responses are
initially required through classical conditioning, therefore
getting rid of a phobia can be achieved through counter
conditioning (‘unlearning” the association between anxiety
and the phobic stimulus)
Steps involved
Step 1
Teach the client a relaxation strategy to use when confronted
with phobic stimulus
e.g. Progressive muscle relaxation, visual imagery, slow
breathing technique (SBT)
Systematic desensitisation
Steps involved
Step 2
Therapist helps the client create a fear hierarchy (or “anxiety
hierarchy”) – a list of feared objects or situations ranked from
least to most anxiety producing. (approx. 10-15 situations rated
and ranked on a 100 point scale).
Step 3
Systematic graduated pairing of items in the hierarchy with relaxation
by working upward through the hierarchy one step at a time.
This can be either “in vivo” (real life) or “visual imagery” (imagined).
No advancement occurs until relaxation is achieved at each step.
Systematic desensitisation
Click me to view
a video about
CBT – behavioural component
Systematic desensitisation
Attempts to replace
fear response with
patient taught
relaxation techniques
gradually introduced to
fear inducing stimulus
while practicing
Fear hierarchy
Treatment of phobias
3. Flooding
- Based on the idea that phobias are learnt through
classical conditioning.
- Occurs when the client is exposed to feared stimulus all
at once for long periods of time until anxiety subsides
- Helps the client to replace feelings of anxiety/fear
with feelings of relaxation
- Can be done “in vivo” or with visual imagery using a
virtual reality device.
- Although effective, is not suitable for everyone and can
increase rather than decrease their phobia.
CBT – behavioural component
Expose the patient to
their fear straight
They will panic at first
Soon realise that
nothing bad has
Biopsychosocial Approach
Health professionals take a holistic approach to
treating simple phobias and consider the following
genetic vulnerability
physiological processes
psychological determinants
family history of anxiety and simple phobia
environmental influences
symptoms and whether the person can function
effectively at work, home and socially.
Example of factors considered
Biological – has the
person been born
with an easily
startled personality
Psychological –
has the person
the perceived
level of danger
Sociocultural –
has the person
learnt to fear
something by
observing other
family members
Combining all the factors
psychological and
factors must be
considered when
treating simple
Step 1 - Full
understanding of all
the elements needed
Step 2- determine
which therapy or
combination of
therapies is suitable
(e.g. CBT, Systematic
desensitisation or
Step 3 – determine if
medication is also
Lutraphobia- Fear of otters