Modification of Cognitive-Behavioral Techniques in the Treatment of a Five Year-Old Girl with Social Phobia

Social phobia is a debilitating anxiety disorder that often goes undetected in young children, but can be effectively treated with cognitive-behavioral interventions. For children and adolescents, treatment usually includes education, social skills training, cognitive restructuring, relaxation training, and exposure. However, for very young children who present with social phobia, it is necessary to adapt treatment to the developmental level of the child. A case illustration demonstrates the way in which cognitive behavioral treatment (CBT) was modified for the treatment of a five year-old girl with social phobia. Several modifications were made, including utilizing novel exposure techniques and emphasizing parent management training in order to promote generalization of treatment gains outside of session.     

Extinction of a phobia of physical examination in a seven-year-old mentally retarded boy—A case study

Counterconditioning is a process in which aversive stimuli that ordinarily evoke emotional or avoidance responses are paired with positive stimuli which evoke incompatible activities. Several sets of operations have been employed to induce these incompatible activities (e.g. food, Jones, 1924; relaxation. Grossberg, 1964; positive imagery, Lazarus and Abramowitz, 1962; pharmacological agents, Friedman, 1966; laughter, Ventis, 1973).Although the Counterconditioning process has been successfully applied to a wide variety of emotional disorders, special problems arise when the procedure is applied to the mentally retarded. First, because of the limitations in cognitive abilities, it is generally impossible to train the subject in either relaxation or positive imagery processes. Consequently, it is necessary to place the child in direct contact with the anxiety-inducing situation. Secondly, it is often difficult to find an anxiety-free situation which is incompatible with the anxiety-arousing situation and which can be practically implemented, particularly when the phobia involved is complex.The purpose of this paper is to describe a case whereby a phobic response of physical examination by male doctors in a 7–yr-old mentally retarded boy was extinguished by pairing the examination with an anxiety-free situation, i.e. an extremely comfortable relationship between the patient and a nurse on the ward. Previous research had indicated that parents and people who have positive relationships with a person might possibly serve as effective anxiety reducers in fear-provoking situations (Jersild and Holmes, 1935).     

The role of mental relaxation in experimental desensitization

Certain evidence indicates that training in peripheral muscle relaxation is not an essential factor in the successful experimental desensitization of phobias. Rachman (1968) has suggested that a sense of calmness or mental relaxation is the necessary component and that all the preliminary training techniques leading to successful desensitization, have, as the basis for their success, the inadvertent induction of this state of mental calmness. The direct induction of mental relaxation then, ought to be at least as effective an adjunct to desensitization as training in muscle relaxation. Using spider phobia as the target behaviour, the present study compared the effectiveness of (a) hierarchy presentation paired with deep muscle relaxation; (b) hierarchy presentation paired with instructions to feel calm and relaxed and alternated with imagining a pleasant scene; (c) a combination of these two procedures paired with hierarchy presentation; and (d) a placebo control procedure. The treatment groups all improved significantly more than controls and there there were no differences between treatments. The results were seen as offering strong support of Rachman's position. Both theoretical and practical implications of the results are discussed with consideration being given to the nature of “mental calmness”.     

Attempted suppression of social threat thoughts: Differential effects for social phobia and healthy controls?

Thought suppression research in the area of social phobia provides conflicting evidence regarding whether individuals demonstrate a general deficit or successful suppression. This paper reports the outcome of two studies using an online thought suppression paradigm measuring activation of target thoughts. Study 1 examined the effects of suppressing social threat stimuli with a healthy control group. Surprisingly, the results showed that participants demonstrated non-suppression of this stimuli class. Study 2 compared individuals with social phobia to a control group using the same stimuli as Study 1. Results revealed that following instructions to suppress social threat stimuli, individuals with social phobia demonstrated successful suppression, whilst the control group, as in Study 1, did not. The lack of suppression of social threat information by the control group may reflect functional impression-management of social threat stimuli. Whereas, successful suppression of these stimuli by individuals with social phobia, may contribute to diminished habituation to such information.     

Effects of experienced disgust on habituation during repeated exposure to threat-relevant stimuli in blood-injection-injury phobia

Despite growing evidence implicating disgust in the etiology of blood-injection-injury (BII) phobia, the relevance of disgust for exposure-based treatment of BII phobia remains largely unknown. Individuals with BII phobia were randomly assigned to a disgust (view vomit videos) or neutral activation (view waterfall videos) condition. They were then exposed to 14 videotaped blood draws, during which fear and disgust levels were repeatedly assessed. Participants then engaged in a behavioral avoidance test (BAT) consisting of exposure to threat-relevant stimuli. Examination of outcome comparing the identical first and last blood-draw clips revealed that fear and disgust toward blood draws was significantly reduced in both groups. Disgust levels were also found to be more intense for the video stimuli relative to fear levels whereas the opposite was true for BAT stimuli. Contrary to predictions, the disgust induction did not enhance reductions in negative responses to the target video or reduce behavioral avoidance. Growth curve analyses did show that individuals with BII phobia exposed to the disgust induction showed greater initial fear levels during repeated exposure than those in the neutral condition. However, this effect was not consistently observed across different analytic approaches. Changes in fear during exposure were also found to be independent of changes in disgust but not vice versa, and greater initial fear levels during repeated exposure to threat was associated with fear and disgust levels during the BAT. The implications of these findings for conceptualizing the role of disgust in etiology and treatment of BII phobia are discussed.     

Recognition and evaluation of emotional prosody in individuals with generalized social phobia: a pilot study

Studies using facial emotional expressions as stimuli partially support the assumption of biased processing of social signals in social phobia. This pilot study explored for the first time whether individuals with social phobia display a processing bias towards emotional prosody. Fifteen individuals with generalized social phobia and fifteen healthy controls (HC) matched for gender, age, and education completed a recognition test consisting of meaningless utterances spoken in a neutral, angry, sad, fearful, disgusted or happy tone of voice. Participants also evaluated the stimuli with regard to valence and arousal. While these ratings did not differ significantly between groups, analysis of the recognition test revealed enhanced identification of sad and fearful voices and decreased identification of happy voices in individuals with social phobia compared with HC. The two groups did not differ in their processing of neutral, disgust, and anger prosody.     

Effects of frontalis tension level on discrimination task accuracy and reaction time

The frontalis muscle is a focal point of many relaxation training programmes, so the effects of varying frontalis tension levels on concurrent task performance need consideration when recommending in situ muscle relaxation. Two experiments are reported; performance on a discrimination task was examined across high, moderate, and low induced frontalis tension. When length of exposure to the task stimuli was unlimited, accuracy of discrimination was affected by tension; when exposure was limited, reaction time was affected. In both experiments the high frontalis tension resulted in better performance than the other levels. Implications for the practice of in situ relaxation are considered.     

The contribution of relaxation to symbolic modeling in the modification of dental fears.

Studies of symbolic modeling suggest that it is a technique which is at least as effective and more efficient (faster) than imaginal desensitization in the treatment of fears (Bandura el al., 1969; Woody and Schaible, 1969). Bandura et al. (1969) assessed the contributions of relaxation to the procedure and found less subjective anxiety and greater positive attitude change with relaxation but no significant differences in oven behavior nor in generalized anxiety reduction. In this study the ‘symbolic modeling only’ subjects received their treatment after they and the other subjects had received the original post-testing assessment. The present experiment was an attempt to assess the contributions of deep muscle relaxation to symbolic modeling without such confounding and with a more nearly clinical population. Dental fear represents a ‘near clinical’ phobia which satisfies Bernstein and Paul's (1971) criteria for analogue desensitization research. That is. dental phobics exhibit a strong, costly and distressing avoidance response which increases in strength as a function of exposure despite high demand.     

A New Model to Facilitate Individualized Case Conceptualization and Treatment of Social Phobia: An Examination and Reaction to Moscovitch's Model

Moscovitch's (2009) model of social phobia is put forth as an integration and extension of previous cognitive-behavioral models. The author asserts that his approach overcomes a number of shortcomings of previous models and will serve to better guide case conceptualization, treatment planning, and intervention implementation for clients with social phobia. Here I respond to these claims and examine the new and not-so-new aspects of Moscovitch's model. Moscovitch provides creative ways of thinking about feared stimuli and maladaptive methods for anxiety management used by clients with social phobia, and these notions may indeed expand our horizons, linking cognitive-behavioral thought to literatures on emotional suppression and emotion regulation. Other aspects of Moscovitch's thesis do provide heuristic and useful approaches to the assessment and treatment of social phobia which may be of great utility to the cognitive-behavioral clinician, but they do not provide a truly new approach to understanding the psychopathology or treatment of social phobia.     

Exposure in vivo vs applied relaxation in the treatment of blood phobia

Eighteen patients with phobia for bloodt, wounds and injuries were treated with exposure in vivo or applied relaxation. They were assessed on different self-report, behavioral and physiological measures before and after treatment. The patients were treated individually for 9 sessions, 1 per week. The within-group comparisons showed that both groups had improved significantly on most of the measures and that these improvements were sustained or furthered at the 6-month follow-up. Furthermore, 10 of the 16 who completed the treatment became blood donors. The between-group comparisons showed exposure to be better than applied relaxation on three of the self-report measures at post-treatment assessment, but not at follow-up. The groups did equally well on the behavioral and physiological measures. The conclusion that can be drawn is that the coping-orientated method of applied relaxation is as effective as exposure in vivo in the treatment of blood phobia.     

Shaping approach responses as intervention for specific phobia in a child with autism

We evaluated contact desensitization (reinforcing approach responses) as intervention for specific phobia with a child diagnosed with autism. During hospital-based intervention, the boy was able to encounter previously avoided stimuli. Parental report suggested that results were maintained postdischarge.     

An augmented reality system validation for the treatment of cockroach phobia

Augmented reality (AR) is a new technology in which various virtual elements are incorporated into the user's perception of the real world. The most significant aspect of AR is that the virtual elements add relevant and helpful information to the real scene. AR shares some important characteristics with virtual reality as applied in clinical psychology. However, AR offers additional features that might be crucial for treating certain problems. An AR system designed to treat insect phobia has been used for treating phobia of small animals, and positive preliminary data about the global efficacy of the system have been obtained. However, it is necessary to determine the capacity of similar AR systems and their elements that are designed to evoke anxiety in participants; this is achieved by testing the correspondence between the inclusion of feared stimuli and the induction of anxiety. The objective of the present work is to validate whether the stimuli included in the AR-Insect Phobia system are capable of inducing anxiety in six participants diagnosed with cockroach phobia. Results support the adequacy of each element of the system in inducing anxiety in all participants.     

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.     

Effects of metronome-conditioned relaxation,metronome-induced relaxation,and progressive muscle relaxation on insomnia

Although several controlled studies have indicated that relaxation can be effectively employed in the treatment of insomnia (Borkovec and Fowles, 1973; Steinmark and Borkovec. 1974; Haynes et al., 1974), the relaxation training procedures thus far utilized have typically necessitated several hours of therapist-client contact. The possibility of a more efficient relaxation procedure for treating insomniacs suggests an attractive alternative to the tense-relax instructions of progressive muscle relaxation (Jacobson, 1938). Brady (1973) has reported that the sound of a metronome set at 60 beats per min is inherently relaxing, and although he has only reported on the effects of the metronome when paired with verbally-induced relaxation (both general suggestions of relaxation and instructions to tense and relax successive muscle groups), he has successfully employed this technique in the treatment of borborygmi (rumbling noises in the abdomen) and essential hypertension (Brady, 1973; Brady, Luborsky and Kron, 1974). If the sound of the metronome alone, which would require minimal therapist-client contact, is sufficient to induce relaxation, the efficiency with which relaxation can be achieved in the treatment of insomnia, as well as other tension-related disorders. may be greatly enhanced.The present study was designed to assess the relaxation-inducing properties of (a) Brady's metronome-conditioned relaxation (metronome plus verbal relaxation instructions), (b) progressive muscle relaxation and (c) metronome-induced relaxation (the sound of a metronome alone) in the treatment of insomnia. In order to provide an evaluation of the effectiveness of relaxation techniques with a broader population than was sampled in previous investigations of this nature, this study included employed adults as well as college students in the subject pool. In addition to its implications for treating insomnia, this study was designed to yield an independent test of the hypothesis that a 60 beat per min metronome sound has the capacity by itself to induce relaxation.     

Working memory capacity in generalized social phobia

Research suggests that understanding complex social cues depends on the availability of cognitive resources (e.g., Phillips, Channon, Tunstall, Hedenstrom, & Lyons, 2008). In spite of evidence suggesting that executive control functioning may impact anxiety (e.g., Eysenck, Derakshan, Santos, & Calvo, 2007), relatively few studies have examined working memory in individuals with generalized social phobia. Moreover, few studies have examined the role of threat-relevant content in working memory performance in clinically anxious populations. To this end, the present study assessed working memory capacity (WMC) in individuals with generalized social phobia and nonanxious controls using an operation span task with threat-relevant and neutral stimuli. Results revealed that nonanxious individuals demonstrated better WMC than individuals with generalized social phobia for neutral words but not for social threat words. Individuals with generalized social phobia demonstrated better WMC performance for threat words relative to neutral words. These results suggest that individuals with generalized social phobia may have relatively enhanced working memory performance for salient, socially relevant information. This enhanced working memory capacity for threat-relevant information may be the result of practice with this information in generalized social phobia.     

Mechanisms of visual threat detection in specific phobia

People with anxiety or stress-related disorders attend differently to threat-relevant compared with non-threat stimuli, yet the temporal mechanisms of differential allocation of attention are not well understood. We investigated two independent mechanisms of temporal processing of visual threat by comparing spider-phobic and non-fearful participants using a rapid serial visual presentation task. Consistent with prior literature, spider phobics, but not non-fearful controls, displayed threat-specific facilitated detection of spider stimuli relative to negative stimuli and neutral stimuli. Further, signal detection analyses revealed that facilitated threat detection in spider-phobic participants was driven by greater sensitivity to threat stimulus features and a trend towards a lower threshold for detecting spider stimuli. However, phobic participants did not display reliably slowed temporal disengagement from threat-relevant stimuli. These findings advance our understanding of threat feature processing that might contribute to the onset and maintenance of symptoms in specific phobia and disorders that involve visual threat information more generally.     

What is so frightening about spiders? Self‐rated and self‐disclosed impact of different characteristics and associations with phobia symptoms

Spider phobia is a common and impairing mental disorder, yet little is known about what characteristics of spiders that spider phobic individuals find frightening. Using screening data from a clinical trial, we explored which characteristics that spider‐fearful individuals (n = 194) rated as having the greatest impact on fear, used factor analysis to group specific characteristics, and explored linear associations with self‐reported phobia symptoms. Second, a guided text‐mining approach was used to extract the most common words in free‐text responses to the question: “What is it about spiders that you find frightening?” Both analysis types suggested that movement‐related characteristics of spiders were the most important, followed by appearance characteristics. There were, however, no linear associations with degree of phobia symptoms. Our findings reveal the importance of targeting movement‐related fears in in‐vivo exposure therapy for spider phobia and using realistically animated spider stimuli in computer‐based experimental paradigms and clinical interventions such as Virtual Reality exposure therapy.     

Memory for facial expressions in social phobia

Memory biases toward threat have been documented in several anxiety disorders, but contradictory findings have recently been reported in social phobics' recognition of facial expressions. The present study examined recognition memory in clients with social phobia, in an effort to clarify previous inconsistent results. Just before giving a speech to a live audience, social phobia clients and normal controls viewed photographs of people with reassuring and threatening facial expressions. The stimuli were later presented again alongside photographs of the same person with a different facial expression, and participants chose which face they had seen before. Individuals with social phobia were less accurate at recognizing previously seen photographs than controls, apparently due to state anxiety. In contrast, social phobics did not show a memory bias toward threatening facial expressions. Theoretical and treatment implications are discussed.     

Applied tension, applied relaxation, and the combination in the treatment of blood phobia

Thirty patients with phobia for blood, wounds and injuries were treated individually with applied tension, applied relaxation, or the combination of these two methods for 5, 9 and 10 sessions, respectively. They were assessed on self-report, behavioral and physiological measures before and after treatment, and at a 6-month follow-up. All groups improved significantly on 11/12 measures, and the improvements were maintained at follow-up. Applying stringent criteria, 73% of the patients were clinically improved at the end of treatment and 77% were so at follow-up. Despite a failure to find between-group differences, on many measures there was a trend favoring applied tension. Since this method is as effective as the other treatments in only half the time, applied tension should clinically be the treatment of choice for blood phobia.     

Attentional Biases for Facial Expressions in Social Phobia: The Face-in-the-Crowd Paradigm

The present study examines the attentional bias hypothesis for individuals with generalised social phobia (GSPs). Socially phobic individuals were hypothesised to exhibit attentional bias towards threat stimuli relevant to interpersonal situations. This hypothesis was tested using the face-in-the-crowd paradigm. GSPs and nonanxious controls (NACs) detected an angry, happy, neutral, or disgust target face in a crowd of 12 distracter photographs. Results indicated that, compared to NACs, GSPs exhibited greater attentional biases for angry than for happy faces in a neutral crowd. GSPs were more slowed down in their performance by happy and angry versus neutral distracters; NACs did not exhibit such sensitivity to distracter type. Finally, GSPs were faster in detecting anger than disgust expressions; NACs detected both types of faces equally quickly. Implications of these findings for the maintenance of social phobia are discussed.