Psychology (9990) | Anxiety disorders and fear-related disorders

🧠 Clinical Psychology: Anxiety Disorders and Fear-Related Disorders (Chapter 1.4)

Hello future psychologists! This chapter dives into one of the most common groups of mental health issues: the anxiety and fear-related disorders. Understanding these conditions—how they are diagnosed, what causes them, and how we treat them—is absolutely central to Clinical Psychology. Don’t worry if the diagnostic terms look complex; we’ll break them down step-by-step!

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1.4.1 Diagnostic Criteria and Measurement

First, let’s define the difference:
Fear is an immediate, intense response to a real, present danger (e.g., seeing a snake).
Anxiety is a future-oriented, excessive worry about potential threats (e.g., worrying about getting bitten by a snake when you are safe at home).

A. Diagnostic Criteria (ICD-11)

The International Classification of Diseases (ICD-11) is a global standard used for classifying mental disorders. We focus on three key disorders in this section:

1. Generalised Anxiety Disorder (GAD)
This is characterised by persistent, excessive, and difficult-to-control worry about many different things (e.g., health, money, work). This worry lasts for many months and significantly interferes with daily life. People with GAD often experience restlessness, fatigue, difficulty concentrating, muscle tension, and sleep disturbances.

2. Agoraphobia
This is a fear of situations where escape might be difficult or help unavailable, often leading to avoidance. It usually involves a fear of being in:

• Public transport (buses, trains)
• Open spaces (car parks, marketplaces)
• Enclosed spaces (shops, theatres)
• Standing in line or being in a crowd
• Being outside of the home alone

Analogy: Think of Agoraphobia as feeling "trapped" or "unsafe" when there is no easy exit.

3. Specific Phobia (Blood-Injection-Injury, or BII Type)
A phobia is an intense, irrational fear of a specific object or situation. The BII type is unique because, unlike most phobias which cause increased heart rate (tachycardia), BII phobia often causes a two-phase response: brief increase, followed by a sudden drop in heart rate and blood pressure (bradycardia), which can lead to fainting (syncope). This is why BII phobias require special treatment techniques!

B. Measures of Anxiety and Fear-Related Disorders

Psychologists use psychometric tests (standardised, reliable, and valid questionnaires) to measure the severity of these conditions:

1. Generalised Anxiety Disorder Assessment (GAD-7)
This is a short, widely used 7-item self-report questionnaire. Patients rate how often they have been bothered by specific anxiety symptoms (e.g., "Feeling nervous, anxious, or on edge") over the last two weeks, typically on a scale from 0 (Not at all) to 3 (Nearly every day). The total score indicates the severity of GAD.

2. Blood Injection Phobia Inventory (BIPI)
The BIPI specifically measures fear and avoidance related to blood, injection, and injury. It is a self-report scale where individuals rate how much fear they feel and how much they avoid specific situations (e.g., seeing someone faint, watching surgery on television).
Example: Mas et al. (2010) demonstrated the utility and reliability of such measures when assessing fear-related disorders.

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1.4.2 Explanations of Fear-Related Disorders

Why do people develop such intense fears and anxieties? Psychologists look at three main approaches:

A. Biological Explanation: Genetic Factors

The biological approach suggests that vulnerability to anxiety disorders, including phobias, may be inherited. If a close relative has an anxiety disorder, an individual is more likely to develop one themselves.

• Focus: Studies often use twin or family comparisons to estimate heritability (the proportion of variance in a trait that can be attributed to genetic factors).
• Evidence: Öst (1992) conducted a study comparing phobic individuals and found that the BII phobia had the highest rate of familial aggregation (clustering within families), suggesting a strong genetic component unique to this specific type of phobia.

Issue & Debate Connection: This explanation heavily supports the nature side of the nature vs. nurture debate and adopts a reductionist view, focusing only on genes.

B. Psychological Explanation: Behavioural (Classical Conditioning)

The behavioural approach explains phobias primarily through learning processes, specifically Classical Conditioning (learning by association).

A phobia is seen as a conditioned fear response acquired when a previously neutral stimulus (NS) becomes associated with a naturally fear-inducing stimulus (Unconditioned Stimulus, UCS).

Key Example: Watson and Rayner (1920) 'Little Albert'

This classic study demonstrated how fear could be conditioned in a nine-month-old infant:

1. Before Conditioning: Albert showed no fear of a white rat (NS). A loud noise (UCS) naturally caused fear/crying (UCR).
2. During Conditioning: Whenever Albert reached for the white rat (NS), a loud clanging noise (UCS) was made.
3. After Conditioning: Albert associated the rat with the loud noise. The white rat became a Conditioned Stimulus (CS), causing a fear response (Crying/Avoidance) even without the noise. This response also showed generalisation (fear extended to other furry white objects, like a rabbit or a Santa mask).

Memory Aid: Classical conditioning uses the association: NS + UCS = UCR. Eventually, CS = CR.

C. Psychological Explanation: Psychodynamic

The psychodynamic approach, pioneered by Freud, suggests that phobias are symbolic representations of unconscious conflicts and anxieties stemming from childhood.

Key Example: Freud (1909) 'Little Hans'

Freud analysed a 5-year-old boy, Hans, who developed a phobia of horses, specifically worrying about horses biting him or falling down.

• Freud’s Interpretation: Hans's phobia of horses was interpreted as a case of displacement. The horse symbolised his father. Hans was supposedly experiencing the Oedipus Complex (desiring his mother and fearing his rival, the father).
• Displacement: Since fear of his father was too distressing to process consciously, Hans's anxiety was unconsciously displaced onto a safer, more distant symbol (the horse).
• Conclusion: Phobias are not about the feared object itself, but about unresolved internal conflicts.

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1.4.3 Treatment and Management of Anxiety Disorders

Effective treatment often targets the psychological or biological causes, aiming to reduce fear and avoidance behaviours.

A. Behavioural Therapy: Systematic Desensitisation (SD)

SD is a form of behaviour therapy based on the principle of Classical Conditioning, specifically counter-conditioning—replacing the fear response with a relaxation response. It can be applied to any fear-related disorder.

The process involves three main steps:

1. Relaxation Training: The patient learns deep muscle relaxation techniques (the new, desirable response).
2. Hierarchy Construction: The patient works with the therapist to create a fear hierarchy—a list of anxiety-provoking situations related to the phobia, ranked from least frightening (e.g., 1/10) to most frightening (e.g., 10/10). Example: seeing a picture of a needle (low) vs. getting an injection (high).
3. Systematic Desensitisation: The patient confronts the hierarchy items one by one, while maintaining a state of relaxation. Only once they are relaxed at one level do they move to the next. This continues until the top item (the actual fear) no longer causes anxiety.

B. Psychological Therapy: Cognitive-Behavioural Therapy (CBT)

CBT is a widely used therapy that addresses both cognitive (thinking) and behavioural (actions) components of anxiety. In the context of phobias, CBT helps patients challenge and change the irrational, negative thought patterns that fuel their fear and avoidance.

For example, a person with social anxiety might believe, "If I speak up in class, everyone will laugh at me." CBT works to test this belief and replace it with a more realistic one, reducing the emotional and physical anxiety symptoms.

C. Applied Tension (Specifically for BII Phobia)

Because BII phobia causes fainting (due to blood pressure drops), standard exposure therapy can be dangerous. Applied Tension is a specific behavioural technique designed to counteract this:

1. The patient learns to tense their large muscle groups (e.g., arms, legs, torso) for about 10–15 seconds when they feel their blood pressure dropping or feel dizzy.
2. This tensing helps increase blood pressure, preventing the patient from fainting, and allows them to successfully tolerate the exposure.

Key Study: Chapman and DeLapp (2013)

This case study investigated the use of CBT combined with Applied Tension to treat a 40-year-old adult with a severe, long-standing Blood-Injection-Injury (BII) phobia.

• Design: Case study (Idiographic approach), using interviews and questionnaires (like the BIPI) for assessment.
• Procedure: The nine-session treatment included gradual exposure to phobic stimuli (e.g., videos of injections) combined with Applied Tension exercises. The patient was also given cognitive restructuring tasks to challenge catastrophic thoughts about needles or injury.
• Findings/Conclusion: The treatment significantly reduced the patient’s fear and avoidance. The patient was successfully able to receive medical injections by the end of the treatment, demonstrating that combined CBT and Applied Tension is an effective management strategy for BII phobia in adults.

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1.4.4 Key Issues and Debates in Anxiety Disorders

When studying anxiety disorders, we must consider how the topic relates to key psychological debates:

1. Nature versus Nurture
Debate: Is anxiety caused by biological factors (genetic predisposition, nature, as suggested by Öst 1992) or by environmental factors (learning and experience, nurture, as shown by Little Albert)?
Conclusion: Most modern explanations adopt an interactionist perspective (e.g., biological vulnerability interacts with stressful life events to trigger the disorder).

2. Determinism versus Free-Will
Debate: Are phobias biologically or environmentally determined (e.g., Classical Conditioning rigidly predicts the fear response)? Or does an individual exercise free-will in choosing to engage in treatment like CBT and actively restructure their thoughts?
Conclusion: Explanations like Classical Conditioning are deterministic, but treatments like CBT emphasise the patient's agency (ability to choose change), leaning towards free-will.

3. Idiographic versus Nomothetic
Debate: Should we focus on general laws (nomothetic, like using the standardised GAD-7 questionnaire on a large sample) or focus on the unique experience of a single person (idiographic, like the case studies of Little Hans or Chapman and DeLapp 2013)?
Conclusion: Clinical Psychology uses both. Diagnosis and therapy guidelines are nomothetic, but effective treatment requires an idiographic understanding of the patient's specific fears and triggers.