PHOBIAS

A definition

A persistent fear of a specific object or situation out of

proportion to the reality of the danger.
Great anxiety and panic arise from the actual exposure to the
feared situation
Recognition that the fear is excessive or unreasonable
Avoidance of the phobic situation
Anxiety v Fear
Anxiety
– Apprehension about a future threat
Fear
– Response to an immediate threat

Both involve physiological arousal

– Sympathetic nervous system

Both can be adaptive

 Fear triggers “flight or fight”
 May save life
 Anxiety increases preparedness
 Moderate levels improve performance
Specific Phobia

Unwarranted, excessive fear of

specific object or situation

Snakes, blood, flying,

spiders, etc. Q: How likely
are you to be bitten by a
spider?

Trigger or feared object is

avoided or endured with
intense anxiety
 Phobias

■ Fear is excessive
– Must be severe enough to cause distress or interfere with job or social
life
■ Avoidance

Two types:
– Specific
– Social
Summary of Major Anxiety Disorders
Phobias

■ Studies tell us that 1:23

people suffer from one
phobia or another

■ 2.5 million people in the UK

■ Phobias are often left

untreated as people try to
cope on their own

■ Safety behaviours are often

developed to aid in
avoidance of the feared
object/situation
Risk Factors

Genetic
– Twin studies suggest heritability
■ About 20-40% for phobias, GAD, and
PTSD
■ About 50% for panic disorder
– Relative w/phobia increases risk
for other anxiety disorders in
addition to phobia
Neurobiological
– Fear circuit over activity
■ Amygdala
■ Medial prefrontal cortex deficits
■ Neurotransmitters
■ Serotonin, GABA, Norepinephrine
Biological explanation of Phobias

• We are born with a preparedness to

learn to fear certain stimuli that were
dangerous to our ancestors (Seligman
1971)

• Children experience patterns of

normative fear throughout their
development

• Parental and others reaction to stimuli

can increase likelihood of children
developing traumas

• Fear information (especially from

adults) increases fear response
The Learning Perspective

THE LEARNING MODEL

■ People acquire fear of a stimulus because they have associated it
with a negative or traumatic outcome
■ Two-Stage Theory (Mowrer 1960)
■ Step 1 – learning to associate a stimulus with an aversive
outcome resulting in a learnt fear response
■ Step 2- learning that by avoiding the stimulus that evokes the
fear, the fear will subside (negative reinforcement)
■ Objects can also become feared – association with trauma
(Barlow 1988)
 Etiology of Specific Phobias

Conditioning
Mowrer’s two-factor
model
– Pairing of stimulus with
aversive UCS leads to fear
(Classical Conditioning)
– Avoidance maintained
though negative
reinforcement (Operant
Conditioning)

11
Etiology of Specific Phobias

Problems with two-factor model

Many people never experience aversive interaction with phobic object

People with phobias tend to fear only certain types of objects (prepared
learning)
Ex:Snakes, insects, blood, heights, etc.

Even phobias linked to Modelling are influenced by prepared learning

Ex: Monkeys acquired fear after watching another monkey exhibit fear
to snake but not flower (Cook & Mineka, 1989)
Percent of People Reporting Conditioning
Experiences Before the Onset of a Phobia
The Cognitive Perspective
• Thinking yourself into being
scared

• Cognitive biases/maladaptive
thinking drive the phobia and
cause the fear response

• Rumination leads to anxiety

• Disgust and sensitivity to

disgust play a prominent role
in some specific phobias,
including emetophobia (van
Overveld et al. 2008), BI
phobias, and certain animal
phobias
 A model of the development and maintenance of specific phobias
Development
Biological preparedness, disposition, developmental stage, culture, experience (classical
conditioning, vicarious learning), memories/images, beliefs

Assumptions
With increased vulnerability to

Trigger
Frightening object or situation

Anxious Cognitions
(thoughts and images concerning stimulus)

OVERESTIMATING THREAT AND CONSEQUENCES/ UNDERESTIMATING COPING AND RESCUE

Hyper vigilance
about physical
symptoms
Anxious mood Physiological symptoms

Increasingly anxious cognitions about Anxious cognitions about symptoms

external triggers (fear of fear)

Safety behaviours Safety behaviours

(related to anxious thoughts about external trigger) (related to fear of fear)

Secondary cognitions From Chapter 8 of Oxford Guide to

Behavioural Experiments in
Cognitive Behaviour Therapy (Kirk
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 A cognitive-behavioural model for the maintenance of specific phobias

Various objects / situations are perceived as

potentially harmful
Avoidance
Encountering the phobic object / situation
Pre-attentive
activation
Catastrophic Autonomic
beliefs arousal
High
degree of
conviction Escape or safety behaviour

The catastrophe does not occur and anxiety

Prevents
reactions dissipate
disconfirmation

Conclusion drawn: The escape / safety

behaviour prevent the catastrophe

The catastrophic belief is confirmed

© Think CBT Ltd. info@thinkcbt.com

01732 808 626 www.thinkcbt.com The phobia remains unchanged
 A vicious circle model of phobic anxiety

Situational Trigger

Physiological Behavioural Subjective

Heart thumping Running away “I might fall”
Sweating “freezing” “This is terrible”
Trembling etc. Shouting for help etc. Fear, embarrassment etc.

Symptoms

Reactions

Physiological Behavioural Subjective

Heart thumping Avoidance, withdrawing “I can’t cope”
etc. from demanding or “I must get out”
Fatigue pleasurable activities Lowered confidence worry,
frustration, fear

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01732 808 626 www.thinkcbt.com
 CBT TREATMENT FOR PHOBIAS

■ Treatment of choice centred around Wolpe’s (1958)

model & Kirk & Rouf (2004) Cognitive and behavioural
model

■ Changing learned responses through exposure to feared

stimulus

■ Alter the learned responses and cognitive biases

■ Five stages of treatment

Interventions may include

• Systematic
desensitisation

• Exposure

• Modelling

• Applied tension

• Cognitive restructuring

• Medication
 Stage 1

Assessment
* Settings
* Triggers
* Responses
* Maintenance factors ( avoidances)
* Secondary gains ( sympathy) relatives and friends may
reinforce avoidance to contain clients distress
* Psycho education
 Stage 2

Goal setting

• What are the clients goals for reducing the phobia?

• What are the perceived benefits for achieving their goal?

• How will their life change if they achieve their goals?

• How will others benefit when they achieve their goals?

• How will they know if they have achieved their goal?

 Stage 3

Measurement (Graded SUDS 1-10

hierarchy, SUDs)
Create and develop
collaboratively a phobia
hierarchy
Example of a hierarchy with a
phobia of spiders.
1. Hold a plastic spider (2)
2. Look at pictures on the
internet of spiders (4)
3. Look at a small dead spider (6)
4. Look at a large dead spider (7)
5. Hold a small dead spider (7)
6. Hold a large dead spider (9)
7. Look at a live small spider in a
container (9)
8. Look at a live large spider in a
container (10
Continue hierarchy until completed
Stage 4
Cognitive interventions

• Explore idiosyncratic beliefs about the fear

• Explore the function of the phobia
• Explore maintenance cognitions
• Clients may fear consequences of change i.e. without the
phobia they may lose relatives and friends concern
• Explore alternative more adaptive ways of obtaining affection
and support
• Explore cognitions regarding reaction of others
• Explore secondary cognitions such as embarrassment, low
confidence, low self-esteem, vulnerability to harm
 Stage 5

Exposure: Flooding – not now used

Exposure: systematic desensitisation
Exposure is designed to test idiosyncratic beliefs not to facilitate
habituation
• Set up exposures collaboratively with the client
• Discuss how and when these will be carried out
• Whenever possible do the exposure with the client in session
• Be aware of the clients anxiety levels at all times make them
explicit
• Allow the client to experience a reduction in anxiety
DO NOT END EXPOSURE ON A HIGH
AFFECT

•Avoid safety behaviours and avoidance behaviour

•Model the exposure with the client
•Reinforce the positive learning from the exposure
•Take your time do not push the client before they are
ready to move on to the next item on their hierarchy
•Set homework that reinforces the learning from the
session
•Acknowledge courage
Desensitisation
Video clip

■ https://www.youtube.com/watch?v=3Y8VKs3__cA
References
■ Think CBT Ltd.
■ Veale, D. (2009)Cognitive behaviour therapy for a specific
phobia of vomiting The Cognitive Behaviour Therapist, 2009,
2, 272–288
■ Olatunji, B.O et al (2010) Efficacy of Cognitive Behavioral
Therapy for Anxiety Disorders: A Review of Meta-Analytic
Findings. The Psychiatric clinics of North America react-
text:50 33(3):557-77
■ Thompson,E.D III, Thomas, Ollendick,T.H, Lars-Goran,O
(2012) Intensive One-Session Treatment of Specific Phobias.
Springer:New York
■