Phobic Disorders - Biological Therapies for Phobic Disorders

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Chemotherapy Anti-anxiety drugs (Benzodiazepines - BZs) - commonly used to reduce anxiety. They slow down the activity of the central nervous system by enhancing the activity of GABA, which is a neurotransmitter that has a quieting effect on many of the neurones in the brain.	Effectiveness of anti-anxiety drugs - Kahn et al (1986) - found that BZs were more effective than a placebo in reducing anxiety. Hildalgo et al (2001) - Found that BZs were more effective than antidepressants. Research has shown that beta blockers can also provide an effective means of anxiety control. However, some studies have found no difference between the results of beta blockers and a placebo in terms of heart rate and feelings of nervousness.
	Effectiveness of antidepressants - Aouizerate et al (2004) – Concluded that SSRIs provide relief for social phobics in 50-80% of cases, a level fairly similar to BZs. However, SSRIs are often considered preferable because they have less side effects.
Beta blockers - are also used to reduce anxiety. They work by reducing the activity of adrenaline and noradrenaline which are part of the sympathomedullary response to stress. This results in a fall in blood pressure, and so less stress on the heart. The person taking the medication will feel calmer and less anxious. Anti-depressants (SSRIs) - Increase levels of serotonin which is a neurotransmitter that regulates mood and anxiety.	Appropriateness of chemotherapy - Not a cure - Generally drugs are not the primary treatment for specific phobias. However they are appropriate for those phobias which are accompanied by panic attacks, although drugs cannot provide a complete treatment as they simply focus on symptoms.
	Appropriateness of chemotherapy - Side effects - Possible side effects of BZs include increased aggressiveness and long-term impairment of memory. Beta blockers have few, if any side effects, whereas there are many problems associated with the use of anti-depressants. SSRIs have been linked to increased suicides.
Psychosurgery Capsulotomy and Cingulotomy - Functionally remove the connection either above or below the organ. They are part of the limbic system which is the region of the brain associated with emotion. Such operations are irreversible and only performed at a last resort.	Appropriateness of chemotherapy - Addiction - Can be a problem with BZs, even when only low doses are given, for this reason the recommendation is that they should be used for a maximum of four weeks.
	Effectiveness of psychosurgery - Ruck et al (2003) - Study of capsulotomy - Reduced anxiety, but there were negative consequences. E.g. 7 tried to commit suicide and there were 2 cases of epileptic seizures. This gives some indication of the success of psychosurgery for treating a range of anxiety disorders. However, any benefits are weighed against the potential for negative.
Deep brain stimulation - Involves placing wires in target areas of the brain. When the current is on, this interrupts target circuits in the brain resulting in a reduction of symptoms. Transcranial Magnetic Stimulation - A large electromagnetic coil is placed above the scalp near the forehead. This creates painless electric currents that stimulate the frontal cortex. This is a reversible, non-invasive method.	Appropriateness of psychosurgery - Psychosurgery is rarely suitable for phobias and then only for extreme cases that have proved otherwise untreatable and that interfere with normal day-to-day functioning. Szasz (1978) - Criticised psychosurgery generally because a person’s psychological self is not something physical and therefore it is illogical to suggest that it can be operated on.
	Ethics with testing effectiveness of drugs - If effective treatments exist, then they should be used as controls when new treatments are tested. Substituting a placebo for an effective treatment does not satisfy this duty, as it exposes individuals to a treatment known to be inferior. Informed consent – Most patients are not informed about the comparative success of drugs versus placebos. They expose themselves to unpleasant side effects even though the pharmacological effects of the drug may be slim.

Phobic Disorders - Cognitive Explanations of Phobic Disorders

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Phobias may develop as a consequence of irrational thinking. Such thoughts create extreme anxiety and may trigger a phobia.	Dysfunctional Assumptions - There is support for the view that phobics have dysfunctional assumptions. Gournay (1989) - found that phobics were more likely than normal people to overestimate risks, which might mean that they are generally more fearful and this results in them being more predisposed to developing phobias.
	A further issue lies with determinism, the cognitive approach states that if you have dysfunctional assumptions, you will become a phobic.
Beck et al (1985) - proposed that phobias arise because people become afraid of situations where fears may occur. Beck also argued that phobics tend to overestimate their fears, increasing the likelihood of phobias.	This explanation suggests that phobias can be reduced to a simple set of principles such as faulty thinking, this is reductionist. It is more important to recognise that the ‘real’ explanations are likely to be a combination of a number of different explanations.
	CBT - the success of CBT as a treatment for phobias can be seen as support for the explanation - it can be argued that, if a therapy changes the dysfunctional assumptions a person has and this leads to a reduction in their phobia, then the dysfunctional assumptions may originally have caused the disorder.

Phobic Disorders - Behavioural Explanations of Phobic Disorders

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The behavioural approach proposes that phobias are acquired through learning. Social Learning Theory – Phobias may be acquired thought modelling the behaviour of other. This theory is based on vicarious learning, which is learning by watching others.	Determinist - Behavioural view suggests that traumatic experiences lead to phobias. The evidence suggests, however that phobias are not inevitable.
	Social Learning Support - An experiment by Bandura and Rosenthal (1966) supported the social learning explanation. In the experiment, a model apparently experienced pain every time a buzzer sounded. Later on, participants who observed this showed an emotional reaction to the buzzer, demonstrating an acquired ‘fear’ response.
Classical Conditioning - Fears are acquired when an individual associates a neutral stimulus with a fear response. The case study of Little Albert can support this approach. Little Albert associated a loud noise with fluffy white objects, resulting in a fear of fluffy white objects such as a white rat. Operant Conditioning – Mowrer (1947) – proposed that learning phobias was a two stage process. The first stage is classical conditioning, then in a second stage, operant conditioning occurs. The avoidance of the phobic stimulus reduces fear and is thus reinforcing.	Little Albert - A case study, so not generalisable to the wider population. Furthermore it was an unethical study, as Little Albert was not protected from physical or psychological harm.
	People with phobias often recall a specific incident when their phobia appeared. This supports the behavioural explanation of phobias, however not everyone who has a phobia can recall such an incident. It is possible that such incidents have occurred, but have been forgotten.

Phobic Disorders - Psychodynamic Explanations of Phobic Disorders

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Freud was the first to offer a psychological explanation for the origins of phobias. He proposed that a phobia was the conscious expression of repressed conflicts. The ego deals with conflict by protecting itself and repressing the emotions into the unconscious. Freud demonstrated his explanation with the case study of Little Hans who had become terrified of horses pulling a laden cart.	Research support – therapies that simply target the symptoms of phobia, are not 100% successful, this is perhaps because they fail to deal with the underlying causes of the phobias.
	There is a tendency in this approach to suggest that phobias can be reduced to a simple set of principles such as repressed anxieties.  Therefore it is reductionist, but this means that other possibilities will not be looked at. It is likely that the ‘real’ explanations are likely to be a combination of a number of different explanations.
Hans had become terrified of horses pulling a laden cart. Freud suggested that Hans' phobia had developed for several reasons: Firstly: Hans once heard a mad saying to a child "Don't put your finger to the white horse or it'll bite you". Hans once asked his mother if she would like to put her finger on his penis. His mother told him this would not be proper, leading Hans to worry that his mother might leave him. Hans projected once source of anxiety onto another - he became afraid of being bitten by a white horse, when in fact he was scared that his mother would leave him. Secondly: Hans saw a horse with a laden cart fall down and thought it was dead. The horse symbolised his wish that his father would die and the laden cart symbolised his mother pregnant with his sister, and when it fell over this was like giving birth. Therefore, the laden cart symbolised his father dying and his mother giving birth - both events that filled him with anxiety.	Little Hans - Only one piece of evidence to support the explanation. This case study could just as easily be explained using classical conditioning.
	Little Hans - Concerns one individual, so cannot be generalised to the wider population. Also, there is a lack of objectivity as both Hans’ father and Freud interpreted the evidence according to their expectations of the origins of phobias.

Phobic Disorders - Biological Explanations of Phobic Disorders

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Genetic Factors Family studies - Research shows that having a family member with a phobia increases the risk that an individual develops a similar disorder. (The family member who already has the disorder is called the proband) Fyer et al (1995) - probands had three times as many relatives who also experienced phobias as the normal controls. Solyom et al (1974) - 45% of phobic patients had at least one relative with the disorder, compared to a rate of 17% of non-phobic controls.	Family and twin studies - There is a considerable variability between disorders. One of the problems with family and twin studies is that they fail to control for shared environmental experiences.
	Behavioural inhibition - Kagan (1994) - identified an infant temperamental type that he described as 'behavioural inhibition' - infants who tend to withdraw from unfamiliar people, objects and situations. He suggested that this behaviour had a genetic basis.
Twin studies - There is a closer concordance between MZ twins than DZ twins, this is because they are genetically identical. This provides support for a genetic basis for phobic disorders. Torgersen (1983) - compared MZ and same-sex DZ twin pairs where one twin had an anxiety disorder with panic attacks. Such disorders were five times more frequent in MZ twin pairs.	Behavioural inhibition - Longitudinal studies have followed children who showed signs of behavioural instability at birth. At primary school age such children were found to have higher ANS activity and also the largest number of specific fears. Similar results were found when looking at children whose parents suffered from panic disorder. Further follow-up studies found that both these groups of children developed significantly more anxiety disorders, supporting the hypothesis that behavioural inhibition to unfamiliar things or situations is genetically based and a risk factor for anxiety disorders.
	The diathesis-stress model - Even at the highest rates it is clear that phobic disorders are not solely genetic and have other factors. This combination can be explained by the diathesis-stress model. This proposes that genetic factors predispose an individual to develop phobias but life experiences play an important role in triggering such responses.
An Evolutionary Approach Ancient fears - Some stimuli are more likely to be feared than others, these could be referred to as ancient fears, in that these stimuli reflected very real fears to our ancestors. Many other stimuli were also part of our ancestral environment, but because they posed no significant danger, are rarely feared. For the same reason, things that are dangers today rarely develop into phobias because they have not been around enough to have influenced our adaptive selection.	Clinical phobias - A lot of the research into prepotency and preparedness that we have looked at is concerned with avoidance responses rather than clinical disorders. Studies of patients suffering from disabling disorders do not support the preparedness explanation. In addition, research has found that clinical phobias do not display the suddenness of onset and resistance to treatment predicted by preparedness.
	Cultural differences - There are significant differences in the kind of phobias reported by different cultural groups. Brown et al (1990) - found that phobic disorders were more common among African American than white American participants even when socioeconomic factors were controlled. This shows that environmental/social factors are important in determining aspects of phobias.
Prepotency - Animals have evolved to respond to potential threats. Those ancestors who were able to respond appropriately to ancient threats were more likely to survive and pass on their genes to subsequent generations. Preparedness - Seligman (1970) - argued that animals, including humans, are biologically prepared to rapidly learn an association between particular (potentially life-threatening) stimuli and fear. Once learned, this fear is difficult to get rid of.	Prepotency - Öhman and Soares (1994) - provided supporting evidence for prepotency effects. 'Masked' pictures were constructed of feared objects in such a way that the animals in the pictures were not immediately recognisable. Participants who were fearful of snakes or spiders showed greater GSR which indicates arousal of the ANS, when briefly shown 'masked' pictures compared to viewing neutral pictures or compared to normal participants. This shows that important components of phobic responses are set in motion before the phobic stimulus is presented in awareness, and these could be prepotent signs.
	Preparedness - The two important predictions arising from the concept of preparedness are: That we learn certain fears more readily Such fears are harder to unlearn McNally (1987) - concluded that although there was firm evidence for enhanced resistance to extinction of fear responses conditioned by 'prepared' stimuli, evidence for rapid acquisition of 'modern' phobias.

Phobic Disorders - Issues of Reliability and Validity

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Reliability refers to the consistency of a measuring instrument. Reliability can be measured in terms of:           Inter-rater reliability           Test-retest reliability Inter-rater - Whether two independent assessors give similar scores. Skyre et al (1991) - assessed inter-rater reliability for diagnosing social phobia by asking three clinicians to assess 54 patient interviews. There was high inter-rater agreement showing that the diagnosis of phobia is reliable.	Research evidence - Reliability has not always been found to be high. Kendler et al (1999) - used face-to-face and telephone interviews to assess individuals with phobias. Over a one month interval, they found a mean agreement of +.46. Reliability over the long term was even lower at +.30. Picon et al (2005) - however, found good test-retest reliability (better than +.80) with a Portuguese version of the SPAI over a 14 day interval. This indicates that reliability can be good at least in the short term.
	Reasons for low reliability - Kendler et al (1999) - suggest that the low reliability found in their study might be due to several factors: Test-retest reliability might be due to poor recall by participants of their fears, for example, people tend to over exaggerate fears when recalling previous distress. Low inter-rater reliability might be due to the different decisions made by interviewers when deciding if the severity of a symptom does or does not exceed the clinical threshold for a symptom.
Test-retest - Whether the test items are consistent. Scales such as SCID take 1-2 hours to complete. The alternative is to use shorter, structured, self-administered scales. These are popular for specific phobias. Hiller et al (1990) - reported satisfactory to excellent diagnostic agreement in a test-retest study using the MDC.	Cultural differences in diagnosis - Cultural norms about 'normal functioning' and 'normal' fears are likely to affect any diagnosis rendering the diagnosis 'invalid'. Judgements may also vary with respect to culturally-relative disorders. A good example of this is provided by taijin-kyofusho (TKS), a culturally distinctive phobia recognised in Japan. This is a social phobia where an individual has a fear of embarrassing others in social situations.  An individual with such a condition would not be diagnosed in this country as having a social phobia, indicating the effect of cultural experiences on the diagnosis of a disorder.
	Diagnosis by computer - Reliability may be improved through the use of computerised scales for assessing phobic and other disorders. Kobak et al (1993) - suggest that increased reliability occurs because there is less opportunity for the administrator to affect th responses that are given. In addition people with social phobias may prefer to answer without the presence of another person because of their fears of negative evaluation.
Validity refers to the extent that a diagnosis represents something that is real and distinct from other disorders and the extent that a classification system measures what it claims to measure. Comorbidity - Is an important issue for the validity of diagnosis. It refers to the extent that two or more conditions co-occur. Research has found high levels of comorbidity between social phobias, animal phobias, generalised anxiety disorder and depression. Such comorbidity suggests that these conditions are not separate entities and therefore the diagnostic category is not very useful.	Comorbidity - The findings on comorbidity have been supported in many other studies. Eysenck (1997) - reported that up to 66% of patients with one anxiety disorder are also diagnosed with another anxiety disorder. The implication is that a diagnosis should simply be 'anxiety disorder' rather than a phobia or OCD.
	The implications of low reliability and/or validity - In order to conduct research on the effectiveness of treatments for phobic disorders researchers require a reliable and valid means of assessing the disorders in the first place.
Concurrent validity - Establishes the value of a new measure of phobic symptoms by correlating it with an existing one. Herbert et al (1991) - tested concurrent validity of the Social Phobia Anxiety Inventory by giving the test and various other standard measures to 23 social phobics. The SPAI correlated well with the other measures. Construct validity - Assesses the diagnostic questionnaires and interviews. This measures the extent that a test for phobic disorders really does measure a target construct of phobias. To do this, clinicians identify possible target behaviours that we would expect in someone with a phobic disorder and see if people who score high on the test for phobic disorders also exhibit the target behaviour.	Support for concurrent validity - Mattick and Clarke (1998) - showed that their Social Phobia Scale (SPS) correlated well with other standard measures. This indicates that there are methods of diagnosis that agree and therefore appear to be measuring something real.
	Support for construct validity - The SPAI correlates well with behavioural measures of social phobia. It also doesn't correlate with behaviours related to other anxiety disorders. However, perhaps this is not surprising because the inventory includes questions about cognitions and behaviours across a range of fear-producing situations. This means that it is likely to correlate with behaviours associated with social phobias.

Addictive Behaviour - The Learning Approach

GAMBLING

INITIATION

• Operant conditioning - any behaviour that produces a consequence that the individual finds rewarding then becomes more frequent. 

MAINTENANCE

• Intermittent reinforcement - people continue to gamble because of the occasional reinforcement that is characteristic of most types of gambling. As a result, they become used to long periods without reward and their gambling behaviour is reinforced by the occasional payout.
• Social approval - this type of behaviour may also be maintained because reinforcement is provided in the form of social approval from others.
• Lambos et al (2007) - found that peers and family members of problem gamblers were more likely to approve of gambling.

RELAPSE

• Conditioned cues - addicts learn (through classical conditioning) to associate other stimuli with their gambling behaviour. These stimuli act as triggers for gambling because they have the ability to increase arousal. If, after a period of abstinence, an individual comes into contact with one of these cues, they are at a higher risk of relapse.
• Approach-avoidance conflict - because gambling has both positive and negative consequences for the individual, they are motivated to approach and to avoid situations where gambling is involved. This creates an approach-avoidance conflict, where motivation fluctuates between wanting to gamble and wanting to stop. Whether or not the gambler will gamble when faced with am urge to do so is related to their ability to control the increased arousal and delay their need for reinforcement.

Smoking

INITIATION

• Availability of role models - Social learning theory explanations of experimental smoking propose that young people begin smoking as a consequence of the social models they have around them who smoke. From this perspective, experimental smoking is primarily a function of parental and peer role modeling and the vicarious reinforcement that leads to young people to expect positive physical and social consequences from smoking.
• Popularity as a positive reinforcer - popularity among peers may also serve as a positive reinforcer in the initiation of smoking.
• Mayeux et al (2008) - found a positive relationship between smoking at age 16 and boys' popularity two years later.

MAINTENANCE

• Classical conditioning - the repetition of the act of smoking thousands of times a year eventually leads to a strong conditioned association between sensory aspects of smoking and the reinforcing effects of nicotine. Although the effects of nicotine in the brain are important when first starting smoking, smoking-related sensory cues rapidly become conditioned stimuli and so activate the same brain areas, making cessation more difficult.

RELAPSE

• Conditioned cues - cues associated previously with receiving nicotine, such as the availability of cigarette smoke, increase the likelihood that the smoker will respond by smoking. 
• Refusal self-efficacy - a concept related to the social learning theory explanation of smoking is self-efficacy, a person's belief in his or her ability to succeed in a particular situation. Among adults, those who smoke more frequently have less confidence in their ability to abstain and so are more likely to relapse.

Evaluation

• Can't explain all forms of gambling - it is difficult to apply the same principles to all different forms of gambling.
• Gender bias - most research is done on only one gender.
• Culture bias - most research is done on individualistic cultures .
• Conditioned cues - supporting evidence by Thewissen et al (2008) - tested the importance of environmental contexts in the urge to smoke. in one room, they repeatedly presented 33 smokers with a cue predicting smoking, whilst in a second room they presented a cue predicting smoking unavailability. Results supported the view that a cue predicting smoking later led to a greater urge to smoke than did a cue associated with smoking unavailability.
• Treatment - Drummond et al (1990) - propose a treatment based on the idea that the cues associated with smoking or other forms of drug taking are an important factor in the maintenance of the habit. The treatment involves presenting the cues without the opportunity to engage in smoking.
• Only some people get addicted - cannot explain social smokers or gamblers not getting addicted.
• Different pathways - it has been suggested that there are different pathways for gambling that predict the likelihood of treatment being successful. People in the 'behaviourally conditioned' pathway are likely to have less severe gambling, so are more likely to consider treatment than the 'emotionally vulnerable gambler' who uses gambling primarily to relieve their aversive emotional states.
• Significance of occasional reinforcement - learning explanations propose that people become 'hooked' on specific activities because they lead to a positive consequence. in real life, this consequence is likely to be occasional rather than consistent, as smoking a cigarette will not always produce a desired positive mood state or relieve a negative one.

Addictive Behaviour - The Biological Approach

GAMBLING

INITIATION

• Genetics - studies have shown that pathological gambling runs in families.
• Shah et al (2005) - found evidence of genetic transmission of gambling in men.

MAINTENANCE

• Pituitary-adrenal response - research suggests that pathological gambling is associated with an underactive pituitary-adrenal response to gambling stimuli.
• Zuckerman et al (1979) - there are individual differences in the need for optimal amounts of stimulation. Sensation seekers look for varied or novel experiences. High sensation seekers have a lover appreciation of risk and anticipate arousal as more positive than do low sensation seekers, are therefore more likely to gamble.

RELAPSE

• Boredom avoidance - the pathological gambler is seen as a person who needs intense stimulation and excitement.
• Blaszczynski et al (1990) - found that poor tolerance for boredom may contribute to repetitive gambling behaviour.

SMOKING

INITIATION

• Role of genetics - family and twin studies estimate the heritability of tobacco smoking to be between 39% and 80%.
• Boardman et al (2008) - a US study of 348 identical twins and 321 same-sex fraternal twin pairs. Estimated heritability for regular smoking to be 42%

MAINTENANCE

• Effects of nicotine - nicotine affects brain chemistry by activating nicotinic acetylcholine receptors (nAchRs) in the brain which leads to release of dopamine.

RELAPSE

• Twin studies - suggest that the ability to quit smoking is also subject to genetic influences.
• Xian et al (2003) - found that 54% of the risk for failure to quit could be attributed to heritability.

Evaluation

• Neglect other factors - such as social aspects, furthermore if smoking addiction is purely biological, it should be able to be treated by pharmalogical methods.
• Animal research - lots of research is into non-human research, the problem is that the animals used aren't similar to humans. Also, research on animals is not moral and the animals have a lower quality of life, however the ends justify means.
• Deterministic - the biological approach states that people with the specific gene will be more susceptible to gambling or smoking.
• Individual differences - other factors are not considered, for example peers and age.
• Reductionist - reduce a complex issue such as smoking or gambling addiction to a simple level of explanation.
• Nature/Nurture - the biological approach looks at nature more than the nurture side of this issue.

Phobic Disorders - Clinical Characteristics of Phobic Disorders

There are seven main characteristics of a phobic behaviour:

1. The individual shows a marked and persistent fear that is excessive or unreasonable.
2. A reaction occurs when the feared situation is near or expected.
3. A response is immediately produced.
4. The individual recognises that the fear is excessive or unreasonable.
5. The fear significantly interferes with the individual's normal routine, occupation or social routine.
6. Where the individual is under 18 years of age, the anxiety must have gone on for at least six months.
7. The anxiety is not accounted for by anything else.

The two key features of a phobic disorder:

1. The phobia interferes with everyday life
2. The individual is aware that the fear is excessive or unreasonable.

There are three types of phobia:

• Specific Phobias
• Situational Phobias
• Socal Phobias