The psychoanalytic view of phobias. Part III: Agoraphobia and other phobias of adults.

This is the third part of a review and commentary on the psychoanalytic literature on phobias. This section takes up agoraphobia and other phobias of adults, and suggests further avenues for interpenetration of psychoanalytic and psychiatric approaches.     

The psychoanalytic view of phobias. Part I: Freud's theories of phobias and anxiety.

This paper initiates a series of communications on psychoanalytic and current psychiatric approaches to the understanding and treatment of phobic syndromes with a review and discussion of Freud's evolving ideas on phobias and anxiety. A list of issues that any theory of phobic syndromes must address is compiled on the basis of Freud's work.     

Acquisition of phobias and anxiety response patterns in clinical patients

The ways in which phobic patients (N = 106; animal-, social- and claustrophobics) acquired their phobias were investigated in the present study. The results showed that a large majority (58%) of the patients attributed their phobias to conditioning experiences, while 17% recalled vicarious experiences, 10% instructions/information and 15% could not recall any specific onset circumstances. There was no clearcut relationship between the ways of acquisition and anxiety components (subjective, behavioral, physiological), nor did the conditioning and indirectly acquired phobias differ in severity. However, some interesting trends emerged in the data, showing that animal phobics who recalled conditioning experiences to a larger extent also responded physiologically. For patients with indirect onset experiences (for all three types of phobias) the reverse was true, i.e. they responded to a larger extent in a cognitive-subjective way, rather than with increased physiological arousal.     

Unprepared phobias: "be prepared".

The weaknesses of the equipotentiality premise are rehearsed and an alternative theory of preparedness, with particular reference to phobias, is outlined. Two clinical cases which appear to be contrary to prediction are described. Although their phobias were unprepared (lack of biological significance, rarity, and probably gradual acquisition) they showed features (high resistance and broad generalization) not predicted by the theory. It is suggested that these features may appear as a result of (i) overlearning. (ii) symbolic transformation or (iii) considerable associated psychopathology.     

Conditioning experiences and phobias

A retrospective study was conducted to examine the extent to which phobias are associated with a conditioning pathway to fear. The Phobic Origin Questionnaire (Öst and Hugdahl, Behav. Res. Ther. 19, 439–477, 1981) was administered to a sample of 91 phobic outpatients (patients with panic disorder with agoraphobia, social phobics, simple phobies). Results show clearly that conditioning experiences occur more frequently than either vicarious or informational, learning experiences, which confirms the findings previously reported by Rimm, Janda, Lancaster, Nahl and Dittmar (Behav. Res. Ther. 15, 231–238, 1977) and by Öst and Hugdahl (1981; Behav. Res. Ther. 21, 623–631, 1983). Yet, conditioning experiences consist mainly of panic attacks in confined environments. The findings also suggest that a considerable number of phobias are based on a combination of different pathways to fear.     

Comparing acceptance and refusal rates of virtual reality exposure vs. in vivo exposure by patients with specific phobias.

The present survey explored the acceptability of virtual reality (VR) exposure and in vivo exposure in 150 participants suffering from specific phobias. Seventy-six percent chose VR over in vivo exposure, and the refusal rate for in vivo exposure (27%) was higher than the refusal rate for VR exposure (3%). Results suggest that VR exposure could help increase the number of people who seek exposure therapy for phobias.     

One-session treatment for specific phobias

A rapid and effective treatment for specific phobias, in which the treatment is done in one single session, is described in detail. The treatment method consists of a combination of exposure in vivo and modeling. The short- and long-term outcome for a consecutive series of 20 patients are reported. Mean treatment time was 2.1 h and at follow-up after an average of 4 yr 90% were much improved or completely recovered.     

Prepared phobias and obsessions: Therapeutic outcome

Sixty-nine phobic and eighty-two obsessional patients, treated at the Maudsley Hospital, were rated for ‘preparedness’, the evolutionary significance of the content and behaviour of the disorder. Reliable ratings (r = 0.78 and 0.90) of the dangerousness of the object or situation to pretechnological man indicated that the content of the large majority of the phobias and obsessions are judged as evolutionarily significant. Degree of preparedness, however, did not predict outcome of therapy, suddenness of onset of the disorder, severity of impairment, intensiveness of the treatment received, or age of onset. Nor was there any significant relationship between preparedness and certain other variables in the obsessional sample: stimulus generalization, effect on life style, impaired reproductive capacity and abnormal personality. The implications of these findings for the hypothesis that human phobias and obsessions are prepared, and for the clinical usefulness of the concept of preparedness, are discussed.     

Disgust sensitivity and contamination fears in spider and blood-injection-injury phobias

Disgust has been implicated in the onset and maintenance of blood-injection-injury (BII) and animal phobias. Research suggests that people with these phobias are characterized by an elevated sensitivity to disgust-evoking stimuli separate from their phobic concerns. The disgust response has been described as the rejection of potential contaminants. Disgust-motivated avoidance of phobic stimuli may therefore be related to fears of contamination or infection. The present study compared BII phobics, spider phobics and nonphobics on two measures of disgust sensitivity and two measures of contamination fears. Positive correlations were found between disgust sensitivity and contamination fear. Specific phobics scored higher than nonphobics on all scales and BII phobics scored higher than spider phobics on contamination fear measures. Furthermore, the contamination fear scales were correlated with the blood phobia measure, but not correlated with the spider phobia measure. The results suggest that while both phobias are characterized by elevated disgust sensitivity, contamination fear is more prominent in BII than spider phobia.     

Retrospective studies of the origins of phobias: A review

Abstract

Studies using retrospective subject reports to investigate etiological models of fears and phobias are reviewed. It is argued that the research effort to date has been plagued by a multitude of methodological problems which bring into question the validity of the major findings. In particular, it is shown that most investigators have begun with the assumption that all phobias are indebted to some traumatic experience with the object or situation and, as a result of this assumption, have predisposed themselves to support learning-based accounts of phobia onset. Other problems, including the lack of demonstrations of adequate levels of inter-rater reliability, test-retest reliability and construct validity are also discussed. Finally, recommendations for future research are made.     

On "stress-induced recovery of fears and phobias"

Jacobs and Nadel (1985) proposed a neurobiological theory to explain the etiology of phobias. Their theory, however, is based on questionable assumptions about clinical fears. The present article is a critique of these assumptions.     

Ways of acquiring phobias and outcome of behavioral treatments

The way of acquisition of phobias was studied in relation to different behavioral treatments for phobias. Ss (N = 183) were clinical patients belonging to six different phobic groups (agoraphobics, claustrophobics, social phobics, animal phobics, blood phobics and dental phobics), and the treatments were categorized as behaviorally focused (exposure in vivo and social-skills training), physiologically focused (systematic desensitization and applied relaxation) and cognitively focused (self-instruction training and fading). Results showed that both for patients with direct conditioning experiences and indirect acquisition those treated with behavioral and physiological methods improved more than those receiving cognitive methods when looking at the change-score data. Regarding the proportion of clinically improved patients there was no difference between treatments among the Ss with a background of conditioning experiences. In the group with indirect acquisition, on the other hand, the cognitive methods were more effective.     

Comparison of behavioral and cognitive-behavioral one-session exposure treatments for small animal phobias

This study evaluated the efficacy of behavioral and cognitive-behavioral one-session exposure treatment procedures with and without programmed generalization for participants with small animal phobias. Forty participants were randomly assigned to the treatment and generalization conditions. Both treatments produced significant improvements from pre-test to post-test and these results were maintained for 1 year. The treatment effect sizes ranged from large to very large across behavioral, self-report, and subjectively rated measures. Participants in the behavioral treatment condition reported that the treatment was significantly more intrusive than participants in the cognitive-behavioral treatment group. The programmed generalization condition did not produce additional measured benefit. The results are discussed in terms of the overall effectiveness of one-session exposure treatment components for small animal phobias.     

Comorbidity in youth with specific phobias: Impact of comorbidity on treatment outcome and the impact of treatment on comorbid disorders

The purpose of the present study was twofold. In an analysis of data from an existing randomized control trial of brief cognitive behavioral treatment on specific phobias (One-Session Treatment, OST; Ollendick et al., 2009), we examined 1) the effect of comorbid specific phobias and other anxiety disorders on treatment outcomes, and 2) the effect of treatment of the specific phobia on these co-occurring disorders. These relations were explored in 100 youth presenting with animal, natural environment, situational, and “other” types of phobia. Youth were reliably diagnosed with the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (Silverman & Albano, 1996). Clinician severity ratings at post-treatment and 6-month follow-up were examined as were parent and child treatment outcome satisfaction measures. Results indicated that the presence of comorbid phobias or anxiety disorders did not affect treatment outcomes; moreover, treatment of the targeted specific phobias led to significant reductions in the clinical severity of other co-occurring specific phobias and related anxiety disorders. These findings speak to the generalization of the effects of this time-limited treatment approach. Implications for treatment of principal and comorbid disorders are discussed, and possible mechanisms for these effects are commented upon.     

Born to fear: non-associative vs associative factors in the etiology of phobias

Poulton and Menzies (Behaviour Research & Therapy 40 (2001) 127-149) review two lines of evidence as supporting a non-associative pathway to the origins of "evolutionary relevant phobias". First, in retrospective studies of mode of onset some recall they have always had this fear. We review here solid evidence that retrospective recall is notoriously unreliable. Second, they note as many nonphobics recall relevant associative learning experiences as do phobics. We argue such studies are very inconclusive because they fail to consider many experiential and personality vulnerability (and invulnerability) factors that strongly impact the outcome of any putative learning experience. Their argument also does not explain the transition from developmental fears to phobias that is central to their thesis. Overall, we call for major methodological improvements in this area, in the context of theoretical developments pointing to interacting vulnerability and invulnerability factors.     

Behavioural approaches to bereavement

Persons who get “hung up” in an unresolved grief reaction appear to be similar in many ways to those who develop phobias. As behaviour therapy approaches to phobias have been highly successful, similar tactics have been tried out with persons involved in pathological grief, with gratifying success. The characteristics of grief reactions are briefly described, as is Eysenck's theory on the development and maintenance of phobias. This theory is applied to explain how and why some people develop pathological grief reactions. A modified flooding technique of confrontation with pain-evoking stimuli is described and some results are presented. The psychoanalytic literature gives indications as to what kinds of emotional reactions the therapist can expect.     

'Nonspecific' rather than 'nonassociative' pathways to phobias: a commentary on Poulton and Menzies

This commentary attempts to clarify the nature of contemporary associative accounts of phobias, and to describe how they might contribute to the explanation of the diversity of phobic aetiologies. It is argued that conditioning-equivalent associations underpin all phobic conditions, and that the role of experimental psychopathology research is to determine how these associations are acquired. The commentary then proceeds to discuss some of the theoretical problems with the nonassociative account of phobias as it is currently described by Poulton and Menzies, and to suggest that some interpretations of their retrospective and prospective data may not be incompatible with contemporary associative accounts. The outcome of this is that it may be more suitable to describe the fourth pathway to phobia acquisition described by Poulton and Menzies as a 'nonspecific' rather than a 'nonassociative' pathway.     

Animal phobias versus claustrophobias: Exteroceptive versus interoceptive cues

The overall purpose of this investigation was to examine heterogeneity among specific phobias. In particular, the goals were to compare features of fear responding between individuals fearful of claustrophobic situations and individuals fearful of spiders/snakes, and to compare their response to hyperventilation challenges. By so doing, specific predictions were tested in relation to a conceptual model of exteroceptive and interoceptive fear cues. Using a nonclinical sample, 19 subjects with spider/snake phobias, 18 nonphobies, and 9 subjects with claustrophobias were exposed on two separate occasions to a live tarantula or python, a small closet, and a hyperventilation challenge. Dependent measures included subjective anxiety, panic attacks, physical symptoms, cognitive symptoms (or, fear of symptoms) and heart rate. In addition, subjects completed a standardized self-report scale that measures fear of bodily symptoms of arousal. It was found that subjects with claustrophobia reported more physical symptoms and cognitive symptoms than did subjects with snake/spider phobias, in response to their fear-relevant stimulus. In addition, claustrophobic subjects were more fearful of hyperventilation challenges and reported more fear of bodily symptoms, than did snake/spider phobic subjects. Finally, subjects with claustrophobia were as fearful of hyperventilation as they were of their fear-relevant stimulus. Theoretical and empirical implications of these findings are discussed.