Introduction
Anxiety is an unpleasant state of high arousal which prevents the sufferer from relaxing and makes it very difficult for them to experience any positive emotion. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), anxiety disorders include: separation anxiety disorder, specific phobia, social anxiety disorder (social phobia), panic disorder, agoraphobia, generalized anxiety disorder and selective mutism (BHATT, 2019). Severity of anxiety disorders is often overseen by the public. For instance, social anxiety is more common than the major autoimmune conditions like Crohn’s diseases or Type 1 diabetes put together. (STATISTICS RELATING TO SOCIAL ANXIETY AND RELATED MENTAL HEALTH CONDITIONS, 2019) There has been strong evidence for the use of psychological therapy as a treatment for anxiety disorders.
In this essay, we will be specifically looking at the evidence for the use of behavioural therapy and psychotherapy as the treatment for phobias. Phobia is defined as an irrational fear of an object or situation. All phobias are characterised by excessive fear and anxiety, triggered by an object, place or situation. The extent of the fear is out of proportion to any real danger presented by the phobic stimulus. Phobias can be divided into (1) specific phobias where the phobic stimulus is a specific object, animal, situation or activity, for example acrophobia which is the phobia of heights. Phobias can be (2) complex phobias which are normally more disabling than simple phobias. Social anxiety disorder (SAD) is an example of complex phobias. It is when you feel restless and nervous when you are in social situations as you might be afraid to humiliate yourself. Complex phobias can majorly affect sufferer’s life as it prevents people from carrying out daily activities. For instance, SAD may lead to people not being able to go to school or work. Simple phobias often are developed during adolescence while complex phobias are usually developed when deep-rooted fear is associated with a particular situation (PHOBIAS, 2018). 2 in a 100 people suffer from phobias at a clinical level where everyday life is affected. There are many psychological treatments for phobias, however the type of treatment used always depends on the type of phobia and the individual. In the case of specific phobias, exposure therapy (behavioural) and cognitive behavioural therapy (CBT) is known to be the most effective treatments.
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MAIN BODY
Specific phobia (SP) involves an extreme, persistent fear of a specific object or situation that's out of proportion to the actual threat of the object or situation, creating life interference and distress (Smitha Bhandari, 2020). The behavioural approach in explaining specific phobias is the two-process theory (O. Hobart Mowrer, 1947) which argues that phobias are acquired through classical conditioning but are then maintained through operant conditioning. The process of classical conditioning explains how we learn to associate something we do not fear (neutral stimulus), for example a dog, with something which triggers a fear response (unconditioned stimulus), for example being bitten. After an association, the dog (conditioned stimulus) now causes a response of fear (conditioned response) and consequently, a phobia of dogs is developed. Operant conditioning is the when the avoidance of the phobic object or situation is negatively reinforced by the reduction of anxiety. Avoidance maintains the fear and preserves the phobia. However, frequent contact with a phobic object may reveal that it is harmless, which will lead to the extinction of the phobia, explaining the effectiveness of exposure therapy.
Systematic desensitization is a form of exposure treatment as direct confrontation with feared stimulus is involved. This approach was developed by Joseph Wolpe (1958). SD uses a counterconditioning method to treat SP. As we can’t feel scared and relaxed at the same time (reciprocal inhibition), associating relaxation and the phobic stimulus together gradually reduces phobic anxiety and treats the SP. During SD, the therapist and patient make an anxiety hierarchy list, starting from a small phobic stimulus, for example, with Arachnophobia, which is the phobia of spiders, they may start with a picture of a spider at the bottom of the list to the most frightening stimulus being on the top of the list which in this case could be having a spider crawling on your hands. Then patients would learn relaxation methods like breathing exercise, meditation or even get prescribed drugs like Valium. In the presence of the therapist, the client then confronts each item in the hierarchy while they are in a state of deep relaxation. They start with the least feared item and move on once they feel relaxed and unafraid in its presence. This confrontation may be real (in vivo) or imagined (in vitro). The process continues until they reach the top of the hierarchy and feel relaxed in the presence of all the items. If the SD works, clients have learnt a new response to the stimulus and no longer associate the object or situation with fear. (McLeod, 2015)
Strong evidence for the effectiveness of SD comes from (Kate B Wolitzky-Taylor 1, 2008). They conducted a meta-analysis that examined adults diagnosed with SP. The effectiveness of exposure treatments relative to a placebo control and non-exposure psychotherapies. The review included 33 studies involving a total of 1,193 participants. Results indicated that exposure-based treatment outperformed placebo conditions and alternative active psychotherapeutic approaches. (Dr. John Hunsley, 2013)
Four additional follow-up studies of systematic desensitization were carried out: one in animal phobia (Barrett, 1969), one in height phobia (Baker, 1973) and two in flying phobia (L. Solyom, 1973). All of these reported that there was no relapse of the initial phobia. In the flying phobia study by Solyom et al., subjects were followed 8 to 24 months after SD. 70% of the 32 patients reported minimal or no anxiety during subsequent flights. Subjects in the other treatment groups did similarly well.
Similarly, another exposure therapy for treating specific phobias is flooding. This approach directly exposes clients to the objects or situations they fear. For example, someone with a fear of heights is taken to the top of a tower block and encouraged to stay there. In theory, flooding the client exposes them repeatedly to the feared stimulus, allowing them to see that there is no basis for their fear, leading to the extinction of the fear. (Higgins, 2013)’s study provides strong evidence for the effectiveness of flooding as it led to more rapid extinction of avoidance responses.
Overall the findings are consistent with qualitative reviews that have concluded exposure-based treatments like SD and flooding are the most potent and durable treatments for SP. However, (Yujuan Choy 1, 2006) emphasized that much more research is needed to investigate the long term effectiveness of therapies and to better understand and prevent relapse. It is suggested that even though successful results for exposure treatments were shown and most phobias responded robustly to in-vivo exposure, high dropout rates and low treatment acceptance may be the explanation for this positive outcome.
On the other hand, exposure-based cognitive behavioural therapy (CBT) appears to be the Canadian Psychology Association’s most commonly used and is often considered the first line of treatment for specific phobias (Barlow, 2002).
CBT is also known to be one of the effective treatments for Social Anxiety Disorder (SAD) which is also known as social phobia. SAD is defined as a collection of fears linked to the presence of other people (Kring, 2007). For instance, during interpersonal interactions, people with SAD are deeply concerned that they embarrass and humiliate themselves, resulting in others judging or laughing at them. SAD can range in severity. For example, some people might be anxious about speaking in public. In contrast, others fear most social situations. Those with a broader array of fears are more likely to experience comorbidity with other mental health problems like depression. Studies have also implied that psychological treatments of social anxiety disorder are effective in adults. (C Acarturk 1, 2008)
Moreover, CBT appears to be more cost-effective than medications for the treatment of social phobia as evidence suggests superiority of psychological interventions over drugs in maintaining long-term treatment effects. (Ifigeneia Mavranezouli, 2015)
Further development of cognitive therapy for SAD was carried out by David Clark (1997) which expands on other psychological treatments. The therapist helps patients learn not to focus their attention internally when in a social situation. They also help patients combat their negative images of how others will react to them. This cognitive therapy has been shown to be more effective than fluoxetine (Prozac) or exposure treatment with relaxation techniques (David M Clark 1, 2003) (Clark, 2006). Further support of the efficacy of cognitive therapy comes from (Ewa Mörtberg 1, 2011). Patients who had received cognitive therapy for social anxiety continued to show positive outcomes 5 years later.
Psychotherapy was compared to antidepressant medications by (John Canton 1, 2012) and they concluded that there was little difference in the effectiveness of these two types of treatment. Conversely, according to long-term follow-up data patients who received psychotherapy were more likely to maintain their treatment gains and the effects were more enduring than those of pharmacotherapy. They also suggested that CBT appears to be more effective than other evidence-based psychological treatments.
Meta-analysis conducted by (Natasha K Segool 1, 2008) examined the efficacy of psychological intervention in the treatment of youth SAD. The researchers compared the effects of CBT and selective serotonin reuptake inhibitor (SSRI) drug treatment. The review included 14 studies involving 332 participants diagnosed with SAD, aged between 5 and 19 years old. The results suggested that CBT produced significant reductions in social anxiety symptoms like general anxiousness and social avoidance which lead to decrease in impairment due to these symptoms. Additionally, CBT treatment resulted in increased social competence. Even though SSRIs was found to be more efficacious than CBT in reducing symptoms, due to the concerns about the use and side effects of SSRIs with youth and the strength of the psychotherapy results, group CBT is highly recommended for treating youths with SAD.
The efficacy of CBT for SAD in adults is well established as shown in the effectiveness review by (Rebecca E Stewart 1, 2009). Results suggested that patients treated with CBT for SAD in clinically representative conditions improved significantly. In addition, CBT for SAD produced significant reductions in depression symptoms. Therefore, it appears that CBT for adult SAD can be effective when used in typical clinical settings.
Conclusion
In conclusion, there is strong evidence for use of psychological therapy for treating anxiety disorders like phobias. However, many studies have suggested that the efficacy of treatments highly depends on the type of phobia and the patient, whether patient is a child or an adult, suffering from a simple phobia or a complex phobia.
Among individuals reporting a lifetime history of suicide attempt, over 70% had an anxiety disorder (NEPON, 2011) Anxiety doesn’t only affect individuals, but also the economy. Nearly 1 in 7 people (14.7%) experience mental health problems in the workplace. Absence from work costs the economy an estimated 15 billion a year annually, 12.7% of total sick days taken in the UK in 2015 is due to mental health problems like anxiety. (STATISTICS RELATING TO SOCIAL ANXIETY AND RELATED MENTAL HEALTH CONDITIONS, 2019). The burden of phobias on individuals, health services and the wider society could be reduced through improved rates of detection and appropriate treatment. Therefore, further research and studies on improving the effectiveness of psychological therapy could be carried out in the future in order to reduce treatment time and increase efficiency of the treatment, making patients recover faster and return to daily life activities, improving the quality of the life of patients and people around them.
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