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Task 2. Fear
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GGZ2024. Anxiety and Related Disorders. Task 2 worked out: Fear. The notes of the tutorial are added in green. For all tasks, see the bundle
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Task 2. Fear!Learning goals
What is specific phobia, and what types of specific phobia exist? (how do they start,
comorbidity, epidemiology) → task (spider, blood injection – differences)
Adams, T. G., Sawchuk, C. N., Cisler, J. M., Lohr, J. M. and Olatunji, B. O. (2014). Specific
Phobias. In Emmelkamp,P. and Ehring,T. The Wiley Handbook of Anxiety Disorders
Definition
According to the DSM-V specific phobias are defined as a marked fear of certain objects,
stimuli, or situations (criterion A). Actual or anticipated exposure invariably provokes an
immediate, intense anxiety reaction, which can be similar to a full-blown or limited-
symptom panic attack (Criterion B). Although the dominant response tendency is avoidance
(Criterion C), phobic individuals may also engage in excessive safety behaviors or remain in
phobic situations in an effort to endure their anxiety. The clinical diagnosis of a specific
phobia also requires that the fear or anxiety is out of proportion to the actual danger posed
by the object or situation (Criterion C), that it is persistent (Criterion E), that it leads to
functional impairment in either personal, social, or occupational domains (Criterion F), and
that it is not due to or better explained by other anxiety/mood disorders, substances, or
organic pathology (Criterion G).
Epidemiology
Specific fears are incredibly common. Research suggests that 41-50% of the general
population experience specific fears during their lifetime, although these fears are rarely
sufficient to warrant a phobia diagnosis. Specific phobia is one of the most prevalent
psychological disorders. Recently, large epidemiological studies suggest an overall lifetime
prevalence rate for specific phobia of ∼12% and a 12-month point prevalence of ∼9%. Of
those with specific phobia the severity of the symptoms is: 48% mild, 30% moderate and
22% severe. Situational phobias are the most common, followed by natural environment,
animal, and BII phobias. Fear of heights is the most common specific phobia.
There are both significant age and sex effects in the prevalence of specific phobia. In general,
specific phobias are more common among adolescents and less common among older adult
populations. The rates of specific phobia are also higher among females compared to males.
Natural course
Animal and BII phobias tend to onset earlier than natural environment and situational
phobias. While specific phobias have an early onset, specific fears appear even earlier.
Specific phobias tend to be chronic and rarely (16%) remit without intervention. However,
the severity tends to be mild to moderate, which may explain the lack of treatment seeking.
A majority of adults with at least one specific phobia were likely to have had at least one
anxiety disorder during childhood or adolescence. Moreover, an adult diagnosis of specific
phobia was significantly associated with a childhood and/or adolescence diagnosis of specific
phobia. The age of onset and chronicity vary as a function of subtype.
,Impairment
While the other anxiety disorders may be more impairing in many circumstances, a diagnosis
of specific phobia can result in significant impairments in several life domains. A positive
relation is found between the number of specific fears and the degree of social and
occupational impairment.
Individuals who met criteria for a specific phobia missed about the same amount of work
and reported similar physical and mental quality of life as those with other anxiety-related
disorders. Individuals with a specific phobia missed, on average, 11% more days of work
than those without a diagnosis of specific phobia. They also reported significantly poorer
mental and physical quality of life. Those with comorbid major depressive disorder (MDD)
and specific phobia reported impairments across multiple domains of quality of life as
compared to those with a singular diagnosis of MDD. This included poorer physical
functioning, poorer role functioning, increased bodily pain, poorer perception of general
health, decreased vitality, and decreased social functioning. Much less is known about
functional impairment and quality of life among specific phobia subtypes. A study found that
the situational phobias, in general, and the fear of being alone, specifically, were associated
with the most interference, the highest probability of seeking professional help, and the
highest use of medication. Conversely, fear of storms was associated with the least
interference and least treatment seeking. Individuals with BII phobia are less likely to pursue
some medical treatments, which may have an impact on their overall health. In older adults,
a current or lifetime diagnosis is related to several health concerns, ranging from increased
risk of nicotine dependence to higher rates of hypertension, gastritis, arthritis, and obesity.
Differential diagnosis
Three components of the process of anxiety are identified: (1) motoric escape and
avoidance, (2) physiologic activation of the sympathetic branch of the autonomic nervous
system, and (3) cognitive appraisals of threat and harm. In specific phobia, physiologic
activation is the pre-potent response which serves to cue and motivate escape when in the
presence of the feared object, and avoidance in anticipation of its occurrence. The cognitive
component addresses overestimation of threat and harm. The phobic knows explicitly what
she is afraid of, but she also knows “how” she is afraid of it. It is these features that
contribute to the distinctiveness of specific phobia relative to other anxiety disorders.
- Social phobia is also focal in nature, but the content of the fear network is interpersonal.
Avoidance of anticipated negative events rather than escape from current ones, and
pervasive dread of future interpersonal events predominate over physiological activation
- In panic disorder (with agoraphobia) it is the panic response itself rather than the
triggers for it that distinguishes panic disorder from specific phobia
- The occurrence of PTSD requires a direct experience that elicited objective harm or the
induction of terror when indirectly experienced. Direct experience is no feature of
specific phobia.
- GAD is most distinguishable. It is characterized by little sympathetic branch autonomic
arousal and predominance of pervasive, vague, context-independent concerns of future
danger and absence of safety
- OCD has various anxious themes (checking for danger, contamination aversion) but,
compared to specific phobic reaction, there is less in the way of physiologic arousal or
arousal reduction associated with repetitious or ritualistic behavior. Obsessions are far
more chronic and repetitive and, at times, are much more bizarrely themed than more
, basic threat cognitions in specific phobias. Compulsions are also much more complex,
repetitive, and bizarre compared to escape and avoidance in specific phobias.
Comorbidity
The likelihood of specific phobia appears to be greater given the presence of another anxiety
disorder. This suggests that a phobia is more likely to be “secondary” to other such
disorders. Specific phobias may also co-occur with nonanxious disorders (manic/hypomanic
episodes, ODD, ADHD, intermittent explosive disorder, and alcohol dependence). The co-
occurrence between specific phobia and personality disorders is not well known.
The specific role of disgust in BII and spider fears
While specific phobias are categorized as disorders of anxiety in the DSM, there is convincing
evidence that some small animal and BII phobias may be better characterized as disorders of
aversion; meaning, these disorders are characterized by escape and avoidance behaviors
that are motivated by fear, anxiety, and disgust, with disgust itself potentially mediating
severity of fear and anxiety.
Research has shown that disgust sensitivity is a robust predictor of spider fears and BII fears.
There is also evidence that state subjective disgust predicts avoidance of spider and
injection/ injury stimuli above and beyond state fear and anxiety. Psychophysiological
research has also shown that spider-fearful and BII-fearful individuals both display
characteristic disgust facial expressions. These data suggest that disgust is a primary
motivator and, perhaps, vulnerability factor underlying the maintenance and etiology of
phobic avoidance and negative reactions to spiders, blood, injections, and injuries.
These findings can be incorporated with Armfield’s cognitive vulnerability model of specific
fears. The general tendency to evaluate noxious stimuli as more disgusting, the specific
tendency to evaluate a phobic stimulus as disgusting, and the tendency to negatively react
to one’s feelings of disgust (disgust sensitivity) are all implicated and interacting in the
etiology, maintenance and expression of spider and BII phobias.
Disgust is a gustatory response that exists to promote disease avoidance. It is thought that
ontogenetic disgust reactions, including those seen in specific phobias, develop via a special
type of classical conditioning, evaluative conditioning. Once conditioned, the association
between disgust and phobic-relevant information tends to be resistant to extinction. Thus,
disgust has an important role in the treatment of spider and BII fears and phobias.
Ayala, E. S., Meuret, A. E., & Ritz, T. (2009). Treatments for blood-injury-injection phobia: A
critical review of current evidence. Journal Of Psychiatric Research. (only relevant parts
introduction)
Blood-injury-injection phobia (BII) is a common and unique phobia. Estimates of lifetime
prevalence of BII phobia range from 3,5% for men and women to as high as 4,9% for women,
and unlike individuals with other specific phobias, 75% of those with BII phobia report a
history of fainting in response to phobic stimuli. The fainting response (emotional fainting) is
characterized as a vasovagal syncope and is described as a two-phase, or biophasic /
diphasic response to BII stimuli. The initial phase involves an increase in heart rate and blood
pressure as is typical of the fight-flight component of an anxiety response. The second phase
is characterized by bradycardia (a sharp drop in heart rate) and hypotension (low blood
pressure) leading to reduced cerebral blood flow and ultimately fainting (not always).
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