Lecture
Anxiety-Phobic Disorders
One of the most common forms of mental pathology, neurotic phobias are found in the general population in 8-9% of people, obsessive-compulsive disorders – 2-3% panic states – fear neurosis, anxiety – 1.5%.
The frequency of phobias in neuroses – up to 44% of cases, most patients are seen in general medical practice, where the prevalence rate reaches 11.9%
In more than 80% of cases, phobias arise during adolescence.
Women suffer from specific phobias 2-3 times more often.
A significant risk of subsequently developing other mental disorders: the risk of developing other anxiety disorders is 6-8.5 times higher than in people without phobic disorders; depressive disorders are 3.7-5.6 times higher; substance abuse is 2 times higher.
Anxiety disorders encompass very diverse clinical manifestations characterized by two features:
The appearance of unusually intense fear that is disproportionate to the situation
Equally pronounced avoidance behavior
Phobia - fear directed at a specific object or a particular situation, and fear neurosis – (an outdated term) generalized, free-floating anxiety
Types of fears. Three forms of fear can be distinguished
Phobic fears - relate to specific objects and situations: agoraphobia, social phobias, and monosymptomatic phobias (specific isolated phobias)
Fluctuating fears - not associated with specific objects or situations and developing in the form of panic (panic disorders or panic attacks)
Generalized fears - arise not in the form of attacks but gradually, and are not associated with specific situations or objects. This form of fear is also called free-floating anxiety.
Neurotic phobias. When defining neurotic phobias, it is most often emphasized that this is an obsessive experience of fear with a clear-cut theme in the presence of sufficient insight.
They intensify in certain situations. Another feature: a vivid, imagery-laden, sensory character
They are extremely distressing to endure because of the ambivalent attitude toward them – a persisting experience of fear alongside an understanding of its groundlessness
An essential feature – pronounced struggle against it
On insight and the struggle against fears:
Full insight only outside of attacks.
The scope of consciousness can vary depending on the intensity of the obsessive phenomena and their form, while the degree of critical attitude and the struggle against them depend also on the content of the obsession
All types of fear cause changes at three levels, which may vary in degree of intensity:
At the level of experience: apprehensions, experiences of harm, thoughts of avoiding fear-inducing situations, etc.
At the level of behavior: avoidance strategies such as flight, evasion, withdrawal from situations, as well as safety signals associated with a specific fear-provoking situation. Safety signals are understood as objects and situations that prevent extremely intense fear from developing, since a means of «immediate help» is usually available (a phone, the presence of a certain person, pills in a bag).
At the physiological level: manifestations accompanying fear, such as rapid heartbeat, tendency to sweating, increased respiratory rate
It is always very important to determine whether an anxiety state has a pathological character or whether it can still be classified as a normal manifestation. This distinction is not always sufficiently clear-cut, but there are criteria that are fairly reliable
Criteria for pathological fear
Excessive intensity of fear (quantitative aspect).
Unusual content and unusual objects causing fear (qualitative aspect).
Inadequacy of the fear reaction to the situation in which it arose.
Chronification of the fear-inducing situation.
The individual's lack of ability to reduce or overcome the fear.
The existence of a limitation, caused by fear, that hinders leading a lifestyle appropriate to the person's age.
Pathological anxiety. Anxiety reaction and avoidance behavior
1) are experienced by people as groundless, inappropriately intense, and occurring too often;
2) they begin to avoid situations that trigger anxiety and lose control over the anxiety;
3) anxiety reactions occur consecutively and last longer than usual;
4) lead to impairment in quality of life
Monosymptomatic fears - Monosymptomatic, specific (isolated) phobias
— phobias confined strictly to a particular situation
— fear of heights, nausea, thunderstorms, domestic animals, dental treatment.
Fear of animals (spiders, dogs, horses, snakes) is especially common.
Such phobias used to be named after their object, but given the variability of such phobias, this principle has been somewhat abandoned.
Monosymptomatic phobias arise mainly in childhood, adolescence, and youth.
In children and adolescents, such fears may develop after finding themselves in certain situations.
Since contact with the feared objects is accompanied by intense anxiety, they subsequently try in every way to avoid them
Main criteria:
1) a distinct fear of specific objects and situations; 2) distinct avoidance of such objects and situations.
The state of fear is accompanied by pronounced autonomic manifestations (sweating, increased urination, tachycardia, cardiovascular lability).
In terms of personality, adolescents are introverted, anxious, low in activity, and closely attached to one of their close relatives.
Family members with similar traits are often present.
Nosophobias
Hypochondriacal phobias (nosophobias) — an obsessive fear of some serious illness, phobias of an «internal stimulus»
Most common are cardiophobia, cancerophobia, and stroke phobia, as well as syphilophobia and AIDS phobia, and lyssophobia (fear of going insane).
The content of obsessive fears is influenced by the current situation in medicine in its personally and socially significant aspects.
At the peak of anxiety (phobic raptus), patients sometimes lose critical awareness of their condition — they turn to the relevant specialists and demand examinations.
More than half are patients with cardiophobia.
With lyssophobia, what frightens is not so much the insanity itself as the possibility of a state arising that cannot be controlled. The fear is accompanied by a feeling of tension, lowered mood, heightened self-control, sleep disturbance, and reduced performance.
Cancerophobia. Patients fix their attention on the slightest changes in bodily sensations, in their appearance, on any details that might indicate illness. With a prolonged course, anxious suspiciousness and egocentrism become more pronounced.
Social phobias
Fear of various socially significant situations, fear of being the center of attention, accompanied by apprehension of negative evaluation by others and avoidance of social situations
a pronounced and persistent fear of one or more social situations in which the individual encounters unfamiliar people or is subjected to evaluation by others.
the individual is afraid of showing symptoms of fear, since they will feel embarrassed. In children, this fear must manifest not only with adults but also with children.
Encountering the frightening social situation almost always triggers an immediate anxiety reaction, which may take the form of a panic attack
In children, the fear may manifest as crying, tantrums, freezing, or a desire to run away or hide
Criteria for diagnosing social phobia (per DSM-IV)
Frightening social situations are avoided or endured with intense anxiety.
Avoidant behavior, a state of anxious anticipation, or severe distress in frightening social situations significantly disrupts the person's normal way of life, interferes with their professional success (or studies), as well as social interactions with other people, or the phobia causes severe distress
Social phobias are a frequent manifestation of anxiety disorder in adolescence.
As social situations become more significant to adolescents, anxiety and fear also take on this focus. They often center around exam situations, eating, or public speaking, contact with the opposite sex, and all forms of behavior in public places.
Adolescents fear that in these situations they will become dizzy, vomit, or be ridiculed.
The fear is accompanied by typical physiological manifestations of anxiety (tachycardia, trembling hands, nausea, frequent urges to urinate, avoidance of eye contact). Patients often consider the somatic symptoms to be the primary problem. Symptoms can escalate to the point of regular panic attacks.
Adolescents are characterized by such features as withdrawal, shyness, low self-esteem, fear of being inadequate, and fear of criticism
Cognitive-behavioral models explaining the emergence and maintenance of social phobia.
The self-representation model and the cognitive vulnerability model have acquired particular significance
The self-representation model – the decisive factor is that the individual sets the goal of making a particular impression on others while doubting their ability to achieve this.
That is, social phobia arises from the expectation or experience of social evaluation in real and imagined situations, from the motivation to make an impression, and from a sense of one's own insufficient effectiveness.
Additional situational and dispositional factors – imagined or actual deficits in social skills and abilities, or a low sense of self-worth, capable of affecting motivation and the perception of one's own effectiveness.
The cognitive vulnerability model – individuals with anxiety disorders assume that they are exposed to uncontrollable external and internal danger. This leads to a state of doubt and insufficient self-confidence.
The individual focuses attention on their own weaknesses or on memories of past failures. Socially anxious individuals continuously assess the degree of potential threat in the flow of events and seek ways to overcome such situations. Cognitive distortions in the form of illogical and negative thoughts about the situation prevent an accurate assessment of the threat and of one's own effectiveness.
A distinctive feature of social phobia is the self-fulfilling prophecy (blushing or not knowing what to say). Anticipated negative experience keeps anxious people from social interaction and thereby reinforces distorted beliefs about the nature of their vulnerability.
Subjective beliefs and predictions increase the likelihood that the individual will become preoccupied with the social situation or will try to avoid it.
The expectation of potentially dangerous situations becomes further sensitized.
As a result, a stream of negative thoughts about one's own inadequacy arises, along with an inability to overcome possible problems.
The resulting physiological arousal serves as further evidence of the existing danger and of the difficulty of coping with the situation.
Beliefs about social situations:
the person begins to think that social situations pose a threat to their sense of self-worth or social standing;
believes that they will be able to solve problems only if their behavior is flawless;
this is unattainable, as they lack the abilities necessary to behave appropriately.
Predictions about social situations:
their behavior will inevitably lead to trouble, embarrassment, rejection, humiliation, or loss of status.
Environmental factors:
sensitization through the influence of the environment (learning processes): the behavior of anxious parents leads to the formation of anxiety in children if the parents communicate their fears to the children and shield them from certain situations (parental attitudes regarding child-rearing);
prior negative experience of contact with a reference group (peers and the opposite sex).
Symptoms of anxiety:
anxious anticipation of the situation;
concentration of attention and focus on socially threatening stimuli;
negative thoughts about oneself, about one's own behavior, and about how others evaluate it;
heightened physiological arousal;
intense concern about how apparent the anxiety symptoms are.
Consequences of anxiety:
real or imagined behavioral disturbances,
perception of one's own behavior and its evaluation by criteria of perfectionism;
evaluating one's own behavior as inadequate;
focusing on the imagined negative consequences of inadequate behavior
Social phobias
Concern that anxiety may be noticed and negatively evaluated by others leads to reinforcing avoidance of social situations and, as a consequence, to negative reinforcement of avoidant behavior.
Over time, an accumulation of serious social deficits may occur, further reinforcing the problem.
Isolated social phobias
Two groups are distinguished: isolated and generalized social phobias.
Monophobias, accompanied by relative restrictions in the sphere of professional or social activity (fear of public speaking, communicating with superiors, performing work tasks in the presence of others, eating in public places).
Isolated social phobias represent a fear of failing to perform habitual actions in front of others, associated with anxious anticipation of failure (expectation neurosis according to E. Kraepelin, 1915), and, as a consequence, avoidance of specific life situations.
Outside such key situations, no difficulties in communication arise.
This group of phobias includes ereuthophobia — the fear of blushing, of appearing awkward or embarrassed in company. Ereuthophobia may be accompanied by fears that others will notice the change in one's facial color. Accordingly, in the presence of others, shyness and embarrassment appear, accompanied by inner tension, muscle tension, trembling, palpitations, and sweating with dry mouth.
Generalized social phobias
Generalized social phobia is a more complex psychopathological phenomenon, which, alongside phobias, includes ideas of inferiority and sensitive ideas of reference.
Disorders of this group most often occur within the framework of scopophobia syndrome (Greek scopto — to joke, to mock; phobos — fear) — the fear of appearing ridiculous, of revealing signs of imagined inadequacy in front of others.
The foreground is occupied by an affect of shame that does not correspond to reality but nevertheless determines behavior (avoidance of communication and contact with people).
+The fear of disgracing oneself may be linked to notions of a hostile evaluation by others of a «flaw» the patient attributes to themselves, and to corresponding interpretations of the behavior of those around them (contemptuous smiles, mockery, etc.).
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