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Phobias, Specific and Social: Recognition and Intervention
Abnormal Psychology · Chapter 11: Anxiety-Based Disorders: Origins and Therapeutic ApproachesSection 11.3 · lesson 41 of 9716 min · free with a free account
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In this lesson
Why knowing a fear is excessive does nothing to reduce it.
- Describe specific phobia and its five subtypes
- Separate social anxiety disorder from ordinary shyness
- Trace the maintenance model of social anxiety
- State how phobias are acquired and how they are treated
Transcript
Everything said in the video, section by section (2,164 words). Read along, or search it.
Anxiety-Based Disorders: Origins and Therapeutic Approaches
Phobias, Specific and Social: Recognition and Intervention
Nearly everyone with a phobia already knows the fear is out of proportion. They can state the real risk accurately, and it does not help at all. That fact is the hinge of this section, and it has a real explanation. We start with what makes a fear a phobia rather than a dislike. Then five subtypes, one of which behaves physiologically unlike all the others. Then social anxiety disorder, and why calling it extreme shyness gets it wrong. Its maintenance model is the most detailed thing here, and it repays attention. We finish with how phobias are acquired, and what actually changes them.
The Definition
Disproportion, and a Cost
A phobia is a marked and persistent fear of a specific object or situation. It is out of proportion to the actual danger, and it is actively avoided. Or else endured, with intense distress. The classification adds three requirements to that. The fear must be present nearly every time the object or situation is met. It must have persisted for an extended period, rather than a few weeks. And it must cause significant distress, or interference with functioning. In ordinary speech, phobia names any strong dislike. That is not what is meant here. Two requirements do most of the separating. Disproportion, and cost. So being frightened of a genuinely dangerous animal is not a phobia. Neither is a fear that never obstructs anything at all. One note first. This material is educational, and is not a basis for diagnosis. Exposure-based treatment is delivered by a clinician, and is not something to attempt alone.
Five Subtypes
Content, Onset, and What Marks Each One
Specific phobia divides into five subtypes, and the divisions do useful work. The animal subtype covers spiders, insects, dogs, snakes, birds, rodents. It is the most commonly reported, and usually begins early in childhood. Its content is strikingly consistent across cultures. We come back to that. The natural environment subtype covers heights, storms, water, and darkness. It also starts in childhood, often with no identifiable initiating event. The situational subtype covers enclosed spaces, flying, elevators, driving, and tunnels. The blood-injection-injury subtype covers blood, injections, injuries, and medical procedures. It begins in childhood, and it frequently runs in families. Now read down the onset column, because one row is different. The situational subtype begins later, in adolescence or early adulthood. A situational fear beginning in adulthood raises a question. Did it follow a panic attack? If it did, it belongs in eleven point two rather than here.
One Apart
The Blood-Injection-Injury Response
One subtype has to be separated from the rest, on physiological grounds. In most phobias the response is sympathetic activation. Heart rate and blood pressure rise. In the blood-injection-injury subtype, many people show a two-stage response instead. An initial rise is followed by a sharp fall in heart rate and blood pressure. That can produce faintness, and in some people actual fainting. This is the one place in the chapter where fainting is a genuine feature. Everywhere else, fainting is a feared outcome rather than a real one. That changes the treatment, because the problem here is a fall rather than a rise. Applied tension is the named adaptation, and it is taught by a clinician. The clinical consequence is substantial, and easy to underestimate. People may avoid blood tests, vaccination, dental care, and treatment for other conditions. So the harm reaches well beyond the distress the fear causes directly. Describing phobias as comical is a common habit, and it misrepresents these conditions.
Insight
Knowing Better Changes Nothing
Most adults with a specific phobia know that the fear is out of proportion. They can state the actual risk accurately, and are often embarrassed by the discrepancy. The fear is not reduced by that knowledge at all. This is not a puzzle unique to phobias. It recurs all through this course. Being able to state that something is safe is propositional knowledge. The learned emotional response is something else, supported by different processes. Updating one does not automatically update the other. So explanation alone is not treatment. Telling someone that spiders in their region are harmless supplies information they already have. What changes the response is new experience with the stimulus itself. Now the second half, which explains who walks through the door. Phobias persist because avoidance prevents disconfirmation. Decades supply no corrective information. Meanwhile the fear gets accommodated. Someone afraid of flying takes trains. Accommodation is invisible until circumstances change, and that is when people present. A job that requires travel. A procedure that cannot be deferred. So ask what has changed, rather than what is wrong.
Social Anxiety
The Feared Outcome Is Evaluation
Social anxiety disorder is marked fear about social situations involving possible scrutiny. The core fear is of acting in a way that will be negatively evaluated. Or of showing anxiety symptoms. Judged inadequate, boring, foolish, or visibly anxious. The situations are avoided, or endured with intense distress. The fear is out of proportion to the actual social risk, and it has persisted. A performance-only presentation is recognized separately. There the fear is restricted to speaking or performing in public. It does not extend to conversations or meeting new people. Its course and treatment differ somewhat, which is why it is named apart. Two things are worth stating plainly. The feared outcome is the evaluation, not the situation. That distinguishes it from agoraphobia, even when the avoided situations are identical. And this is not extreme shyness. Onset is early and the course is chronic if untreated. Alcohol use as a way of managing social situations is a recognized pattern here.
Shyness Or Disorder
Four Dimensions, and One That Settles It
Four dimensions separate shyness from the disorder, and the last one settles it. Intensity. In shyness, discomfort settles once the interaction is under way. In the disorder the fear persists, and often intensifies, with prominent physical symptoms. So ask what happens over the course of an interaction, not just at the start. Breadth. Shyness is usually confined to unfamiliar people, or particular settings. The disorder spans most situations where scrutiny is possible, familiar ones included. Avoidance. A shy person enters the situation, if reluctantly. In the disorder it is avoided outright, or entered with safety behaviors. Ask what has been declined, not what has been disliked. Functional cost. This is the decisive dimension, and here is why. The first three are continuous, and a person can sit anywhere along them. What the fear has actually cost has an answer. Shyness has a personality cost. The disorder has a life cost.
Maintenance
Why the Evidence Is Never Collected
The account that organizes current treatment came from David Clark and Adrian Wells. Published in nineteen ninety-five, and its central claim is counter-intuitive. The difficulty is not maintained by what happens in social situations. It is maintained by what the person does during and around them. Which prevents them from ever finding out what happens. Four components carry it. Anticipatory processing. Beforehand, the person rehearses the event and predicts how badly it will go. They arrive already primed to detect confirmation. Negative self-image. On entering, they construct an impression of how they appear. Typically visibly anxious or inadequate. And they treat that impression as accurate information. Self-focused attention. This is the pivotal move, so slow down here. Attention shifts inward, to their own sensations, words, and imagined appearance. Attentional resources are finite, so the person is not observing the room. Their sense of the situation is built from inside, not from anything external. Post-event rumination. Afterwards the event is reviewed, with attention drawn to perceived failures. The reviewed version becomes the remembered one, so the memory is worse than the event. That explains something odd. Avoidance can grow over time with no new bad experiences. Safety behaviors here have an additional and unfortunate property. Several of them produce the very impression the person fears. Saying little to avoid saying something foolish reads as aloofness. Avoiding eye contact to escape scrutiny reads as disinterest. Gripping a glass to hide a tremor makes the hand shake more. The person then observes an awkward interaction they partly produced, and takes it as confirmation.
Acquisition
Three Pathways, One Treatment Implication
Chapter five supplied the mechanisms, and they are applied here rather than re-taught. A neutral stimulus paired with an aversive event comes to elicit fear. Two-factor theory adds that avoidance then maintains it, through negative reinforcement. Rachman's three acquisition pathways are the framework used here. Direct conditioning is a frightening or painful experience with the stimulus itself. A dog bite in childhood, followed by fear of dogs. Observational learning is watching someone, often a caregiver, respond fearfully. A child who repeatedly sees a parent react with alarm to spiders. Information transmission is verbal or media-conveyed information that a stimulus is dangerous. Repeated warnings, or coverage of rare catastrophic events, producing fear of flying. Now read the implication column across all three. It is broadly the same. So someone who recalls no originating event can still be treated effectively. The acquisition history is interesting. The maintenance is what treatment addresses. That matters, because a purely conditioning account has a real difficulty. Many people with phobias recall no conditioning event. And many who have had a frightening experience never develop a phobia of it. Conditioning is not irrelevant. It is insufficient on its own. One more pattern needs explaining. Phobic content is not distributed randomly. Fears of snakes, spiders, heights and enclosed spaces are common. Fears of electrical sockets and stairs are rare, and those cause far more actual harm. Preparedness holds that we acquire fear more readily to stimuli that posed ancestral danger. Such associations are learned faster, with less exposure, and they extinguish more slowly.
Differential
The Question Is Always What Is Feared
Four differentials, and every one turns on the same question. What does the person actually expect to happen? Specific phobia against panic-driven avoidance. Both avoid situations. In specific phobia the feared outcome sits in the situation. The elevator will fail. The dog will bite. In panic-driven avoidance the feared outcome is an attack, and its consequences. Social anxiety against agoraphobia. Here the situations overlap heavily. In social anxiety the feared outcome is negative evaluation. In agoraphobia it is being unable to escape, or to obtain help. Someone who does not mind what others think, but could not get out, is agoraphobic. Social anxiety against autistic social difficulty. Both involve reduced social participation. They can also co-occur, so this is not an either-or by default. In social anxiety the person typically wants contact and has the social understanding. They fear evaluation, and the difficulty is confined to situations where scrutiny is possible. In autistic social difficulty, the difficulty spans communication and interaction across contexts. It has a developmental history from early childhood, and is not driven by fear of judgment. That differential needs developmental history, which lies beyond the scope of this section. And finally, either of these against a realistic response. Someone avoiding a genuinely dangerous situation is responding appropriately. Disproportion to actual danger is a requirement, not a formality.
Treatment
Exposure, and What Has To Be Added
Exposure-based approaches have the strongest evidence base of any treatment in this chapter. For specific phobia the evidence is among the strongest in the whole field. The rationale follows five point four. Avoidance prevents disconfirmation. So what changes the fear is new experience with the feared stimulus. Under conditions that permit the expected catastrophe to fail to occur. Exposure is planned and delivered by a trained clinician, and it is graded. It is conducted with attention to safety behaviors, for the reason established earlier. Exposure with safety behaviors intact lets the person credit the outcome to them. Unguided self-directed exposure can entrench a fear rather than reduce it. Most often by ending while distress is still rising, which teaches escape. For social anxiety, exposure alone is generally insufficient. The person can enter social situations repeatedly without ever collecting the evidence. So treatment adds cognitive work on evaluation beliefs, and attention training. Attention is shifted outward to the situation, rather than inward to the self. Work on anticipatory processing and post-event rumination is included for the same reason. Social skills components fit where a genuine skills deficit exists, which is less often than assumed. Most people with social anxiety have adequate skills, disrupted by self-focused attention. Treating a performance problem as a skills problem misdirects the work. Medication is described by class only, and certain antidepressant classes have evidence in social anxiety.
What To Carry
Durable Claims From This Section
Gather this into claims worth keeping. Disproportion and functional cost separate a phobia from a dislike or a caution. The blood-injection-injury response falls rather than rises, and it obstructs health care. Insight does not dissolve fear, because knowledge and learned emotion update separately. People present when circumstances remove the accommodation, not when the fear worsens. Social anxiety fears evaluation. Agoraphobia fears being unable to escape or get help. Self-focused attention is pivotal, because it makes disconfirming evidence unavailable. Three acquisition pathways lead to broadly the same treatment implication. Preparedness explains the distribution of phobic content, but not who develops a phobia. Behavioral inhibition, from three point three, predicts later anxiety, and social anxiety especially. For specific phobia, response to exposure is strong and durable, often in a few sessions. For social anxiety the picture is good but more variable, with residual symptoms in many.
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