Hypnotherapy In Adelaide

 

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Clinical Phobias

Psychologists and psychiatrists classify most phobias into three categories and, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition such phobias are considered to be sub-types of anxiety disorder.  The three categories are:

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1.Social phobia: fears other people or social situations such as performance anxiety or fears of embarrassment by scrutiny of others, such as eating in public. Overcoming social phobia is often very difficult without the help of therapy or support groups. Social phobia may be further subdivided into generalized social phobia

 (also known as social anxiety disorder or simply social anxiety).

specific social phobia, in which anxiety is triggered only in specific situations. The symptoms may extend to psychosomatic manifestation of physical problems. For example, sufferers of paruresis find it difficult or impossible to urinate in reduced levels of privacy. This goes far beyond mere preference: when the condition triggers, the person physically cannot empty their bladder.

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2. Specific phobias: fear of a single specific panic trigger such as spiders, snakes, dogs, water, heights, flying, catching a specific illness, etc. Many people have these fears but to a lesser degree than those who suffer from specific phobias. People with the phobias specifically avoid the entity they fear.

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3. Agoraphobia: a generalized fear of leaving home or a small familiar 'safe' area, and of possible panic attacks that might follow. It may also be caused by various specific phobias such as fear of open spaces, social embarrassment (social agoraphobia), fear of contamination (fear of germs, possibly complicated by obsessive compulsive disorder) or PTSD (post traumatic stress disorder) related to a trauma that occurred out of doors.

Phobias vary in severity among individuals. Some individuals can simply avoid the subject of their fear and suffer relatively mild anxiety over that fear. Others suffer full-fledged panic attacks with all the associated disabling symptoms. Most individuals understand that they are suffering from an irrational fear, but they are powerless to override their initial panic reaction.

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Specific phobias

As briefly mentioned above, a specific phobia is a marked and persistent fear of an object or situation which brings about an excessive or unreasonable fear when in the presence of, or anticipating, a specific object; furthermore, the specific phobias may also include concerns with losing control, panicking, and fainting which is the direct result of an encounter with the phobia. The important distinction from social phobias are specific phobias are defined in regards to objects or situations whereas social phobias emphasizes more on social fear and the evaluations that might accompany them.

The DSM breaks specific phobias into five subtypes: Animal, Natural Environment, Blood-Injection-Injury, Situational, and Other. In children, phobias involving Animals, Natural Environment (darkness), and Blood-Injection-Injury usually develop between the ages of 7 and 9, and these are reflective of normal development. Additionally, specific phobias are most prevalent in children between ages 10 and 13.

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Diagnosis

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Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.

The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.

The phobic situation(s) is avoided or else is endured with intense anxiety or distress.

The avoidance, anxious anticipation or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

In individuals under the age of 18, the duration is at least 6 months.

The anxiety, panic attack, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive Compulsive Disorder (e.g., fear of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), Separation Anxiety Disorder (e.g., avoidance of school), Social Phobia (e.g, avoidance of social situations because of fear of embarrassment), panic disorder With Agoraphobia, or Agoraphobia Without History of Panic Disorder.

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Social phobia

The key difference between specific phobias and social phobias is social phobias include fear of public situations and scrutiny which leads to embarrassment or humiliation in the diagnostic criteria. In social phobias, there is also a generalized category which is included as a specifier below. Unlike specific phobias which may develop before the age of 10, social phobias are typically not present until pubertal transition. After this transition, the prevalence of social phobia increases with age. Many adolescents who develop a social phobia consequentially become rejected by their peers. As interpersonal dysfunction is a risk factor for depression, there are some negative outcomes for adolescents with social phobia. For example, about 20% of adolescents diagnosed with a social phobia also suffer from depression and use alcohol or other substances.

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Diagnosis

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A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. Note: In children the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.

The person recognized that the fear is excessive or unreasonable. Note: In children this feature may be absent.

The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

In individuals under age 18, the duration is at least 6 months.

The avoidance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g. Panic Disorder With or Without Agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, schizoid personality disorder).

If a general medical condition or another mental disorder is present, the fear in Criterion A (Exposure to the social or performance situation almost invariably provokes an immediate anxiety response) is unrelated to it, e.g., the fear is not of stuttering, trembling in parkinsons disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa.

Specify if:

Generalized: if the fears include most social situations (also consider the additional diagnosis of  avoidant personality disorder).

Notice the severe overlap between specific and social phobias which is indicative of the nature between the two. The differences from specific phobias unanimously lay only in the word "social".

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 Neurobiology

Brain regions involved

Beneath the later fissure in the cerebral cortex, the insula, or insular cortex, of the brain has been identified as part of the limbic system, along with cingulated gyrus, hippocampus, corpus collosum, and other nearby cortices. This system has been found to play a role in emotion processing and the insula, in particular, may contribute through its role in maintaining autonomic functions. Studies by Critchley et al. indicate the insula as being involved in the experience of emotion by detecting and interpreting threatening stimuli. Similar studies involved in monitoring the activity of the insula show a correlation between increased insular activation and anxiety.

In the frontal lobes, other cortices involved with phobia and fear are the anterior cingulate cortex and the medial prefrontal cortex. In the processing of emotional stimuli, studies on phobic reactions to facial expressions have indicated these areas to be involved in processing and responding to negative stimuli. The ventromedial prefrontal cortex has been said to influence the amygdala by monitoring its reaction to emotional stimuli or even fearful memories.Most specifically, the medial prefrontal cortex is active during extinction of fear and is responsible for long term extinction. Stimulation of this area decreases conditioned fear responses and so it can be said that it’s role is in inhibiting the amygdala and its reaction to fearful stimuli.

The hippocampus is a horseshoe shaped structure that plays an important part in the brain’s limbic system because of its role in forming memories and connecting them with emotions and the senses. When dealing with fear the hippocampus receives impulses from the amygdala that allows it to connect the fear with a certain sense, such as a smell or sound.

Amygdala's role in memory and fear responses

The amygdala is a “almond shaped” mass of nuclei that is located deep in the brain’s medial temporal lobe, which processes the events associated with fear, as well as being linked to anxiety disorders and social phobias. The amygdala's ability to respond to fearful stimuli occurs through the process of fear conditioning. Similar to classical conditioning,  the amygdala learns to associate a conditioned stimulus with a negative or avoidant stimulus, creating a conditioned fear response that is often seen in phobic individuals. In this way the amygdala is responsible for not only recognizing ceratin stimuli or cues as dangerous, but plays a role in the storage of threatening stimuli to memory. The basolateral nuclei (or basolateral amygdala) and the hippocampus interact with the amygdala in the storage of memory, which suggests why memories are often remembered more vividly if they have emotional significance

In addition to memory, the amygdala also triggers the secretion of hormones that affect fear and aggression. When the fear or aggression response is initiated, the amygdala releases hormones into the body to put the human body into an "alert" state, which prepares the individual to move, run, fight, etc.This defensive "alert" state and response is generally referred to in psychology as the flight or flight response.

Inside the brain, however, this stress response can be observed in the hypothalamic pituitary adrenal axis (HPA).This circuit incorporates the process of receiving stimuli, interpreting it, and releasing certain hormones into the blood stream. The parvocellular neurosecretary neurons of the hypothalamus release corticotropin releasing hormone (CRH) which is sent to the anterior pituitary. Here the pituitary releases adrenocorticotropic hormone (ACTH) which ultimately stimulates the release of cortisol. In relation to anxiety, the amygdala is responsible for activating this circuit, while the hippocampus is responsible for suppressing it. Glucocorticoid receptors in the hippocampus monitor the amount of cortisol in the system and through negative feedback can tell the hypothalamus to stop releasing CRH.

Additionally, recent studies on mice engineered to have high concentrations of CRH showed higher levels of anxiety, while those engineered to have no or low amounts of CRH receptors were less anxious. In phobic patients, therefore, high amounts of cortisol may be present, or alternatively, there may be low levels of glucocorticoid receptors or even serotonin (5-HT).

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Disruption by damage

For the areas in the brain involved in emotion—most specifically fear— the processing and response to emotional stimuli can be significantly altered when one of these regions becomes lesioned or damaged. Damage to the cortical areas involved in the limbic system such as the cingulate cortex or frontal lobes have resulted in extreme changes in emotion. Other types of damage include kluver bucy syndrome and urbach wiethe disease. In Klüver-Bucy syndrome, a temporal lobectomy, or removal of the temporal lobes results in changes involving fear and aggression. Specifically, the removal of these lobes results in decreased fear, confirming its role in fear recognition and response. Bilateral damage to the medial temporal lobes, which is known as Urbach-Wiethe disease exhibits similar symptoms of decreased fear and aggression, but also an inability to recognize emotional expressions, especially angry or fearful faces.

The amygdala’s role in learned fear includes interactions with other brain regions in the neural circuit of fear. While lesions in the amygdala can inhibit its ability to recognize fearful stimuli, other areas such as the ventromedial prefrontal cortex and the basolateral nuclei of the amygdala can affect the regions ability to not only become conditioned to fearful stimuli, but to eventually extinguish them. The basolateral nuclei, through receiving stimulus info, undergo synaptic changes which allow the amygdala to develop a conditioned response to fearful stimuli. Lesions in this area, therefore, have shown to disrupt the acquisition of learned responses to fear. Likewise, lesions in the ventromedial prefrontal cortex (the area responsible for monitoring the amygdala) have shown to not only slow down the speed of extinguishing a learned fear response, but also how effective or strong the extinction is. This suggests there is a pathway or circuit among the amygdala and nearby cortical areas that process emotional stimuli and influence emotional expression, all of which can be disrupted when an area becomes damaged.

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 Epidemiology

Phobias are a common form of anxiety disorders and distributions are heterogeneous by age and gender. An American study by the National Institute of Mental Health (NIMH) found that between 8.7% and 18.1% of Americans suffer from phobias, making it the most common mental illness among women in all age groups and the second most common illness among men older than 25. Between 4% and 10% of all children experience specific phobias during their lives. and social phobias occur in 1% to 3% of children and adolescents.

A Swedish study found that females have a higher incidence than males (26.5% for females and 12.4% for males). Among adults, 21.2% of women and 10.9% of men have any single specific phobia, while multiple phobias occur in 5.4% of females and 1.5% of males. Women are nearly four times as likely as men to have a fear of animals (12.1% in women and 3.3% in men) — a higher dimorphic than with all specific or generalized phobias or social phobias. Social phobias are more common in girls than in boys, while situational phobia occurs in 17.4% of women and 8.5% of men.

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 Etiology

 Environmental

Much of the progress in understanding the acquisition of fear responses in phobias can be attributed to the Pavlovian Model which is synonymous with Classical Conditioning.  Myers and Davis (2007) describe the acquisition of fear as when a conditioned stimulus (e.g., a distinctive place) is paired with an aversive unconditioned stimulus (e.g. a electric shock) to an end result in which the subject exhibits a conditioned feared response to the distinctive place (CS+UCS=CR). For how this model works in the context of phobias, one simply has to look at the fear of heights, or acrophobia. In this phobia, the CS is heights such as the top floors of a high rise building or a roller coaster. The UCS can be said to originate from an aversive or traumatizing event in the person's life such as being trapped on a roller coaster as a child or in an elevator at the top floor of a building. The result of combining these two stimuli leads to a new association called the CR (fear of heights) which is simply the CS (heights) transformed by the aversive UCS (being trapped on a roller coaster or elevator) leading to the feared conditioned response. This model does not suggest that once you have a conditioned feared response to an object or situation you have a phobia. As listed above, to meet the criteria for being diagnosed with a phobia one also has to show symptoms of impairment and avoidance. In the example above, for the CR to be classified as a phobia it would have to exhibit signs of impairment due to avoidance. Impairment, which can be considered along the same lines as a disability from a clinician's standpoint, is defined as being unable to complete tasks in one's daily life whether it be occupational, academical, or social. In the recent example, an impairment of occupation could result from not taking on a job solely because its location happens to be at the top floor of a building, or socially not participating in a social event at a theme park. The avoidance aspect is defined as behavior that results in the omission of an aversive event that would otherwise occur with the goal of the preventing anxiety. The above direct conditioning model, though very influential in the theory of fear acquisition, should not suggest the only way to acquire a phobia. Rachman proposed three main pathways to acquire fear conditioning involving direct conditioning, vicarious acquisition and informational/instructional acquisition.

As experimentation with the aforementioned direct conditioning modeling continued, it became increasingly evident that more than just classical conditioning can influence the onset of a phobia. Rachman (1978) proposed that vicarious acquisition was a critical component to the etiology of phobias, so it was decided to include information and instruction from the parent and family members to better understand its onset. Of the research conducted in this area, one of the best examples of how vicarious conditioning, more specifically modeling, effects the acquisition of a phobia can be said to have come from Cook & Mineka's (1989) work on rhesus monkeys. In this experiment, Cook & Mineka, through the use of video, appraised 22 rhesus monkeys on their fear to evolutionary relevant stimuli (e.g. crocodiles and snakes), and evolutionary irrelevant stimuli (e.g. flowers and artificial rabbits) to see if fear conditioning using the direct conditioning model (Pavlov's model) leads to fear acquisition (or more specifically the conditioned fear response). The results of the research showed that after 12 sessions the rhesus monkeys acquired a fear to the evolutionary relevant stimuli and not to the evolutionary irrelevant stimuli; furthermore, the experiment also revealed that when they exposed monkeys to other monkeys that interacted with snakes without showing fear, this group did not acquire the fear which supports the theory of vicarious conditioning through modeling. According to Pavlov's theory of classical conditioning, the experimenters should have been able to condition a feared response within the rhesus monkeys to the evolutionary irrelevant stimuli because the Pavlovian model posits that any UCS can elicit a CR. The result show the necessary augmentation of the Pavlov model with the vicarious acquisition model.

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Evolutionary

The circumstance that specific phobias tend to be directed disproportionately against certain objects such as snakes and spiders may have evolutionary explanations. In this view phobias are adaptions that may have been useful in the ancestral environment. On the savanna, unlike dangers such as large predators, snakes and spiders tend to be hidden from view until very close and may be a particular danger to infants and small children, favoring the development of an instinctive fearful response. This view does not necessarily hold that phobias are genetically inevitable. Instead, there may be a genetic predisposition to learn to fear certain things more easily than other things.

Similarly, primary agoraphobia may be due to its once having been evolutionary advantageous to avoid exposed, large open spaces without cover or concealment. Generalized social phobia may be due to its once being usually very dangerous to be confronted by a large group of staring, non-kin, unknown, and not smiling strangers.

Sexual dimorphism, with women having much higher incidence of phobias than men, may be a result of selection during the Mesozoic (mammalian) period reflecting the higher cost to progeny of the loss of nursing females compared to "expendable" males.