Understanding anxiety and fear-related disorders

Anxiety and fear-related disorders involve excessive fear or anxiety that disrupts daily life. Fear is an emotional response to a real or perceived immediate threat, while anxiety relates to anticipation of future threats. These disorders include phobias, which are intense, irrational fears of specific objects or situations. Treatments aim to reduce symptoms by addressing behavioural, cognitive, and physiological aspects, often combining relaxation, exposure, and cognitive restructuring.

Behavioural therapy: systematic desensitisation

Systematic desensitisation is a behavioural therapy technique used to treat phobias by gradually reducing fear responses. It is based on the principle of reciprocal inhibition, which means that relaxation and fear cannot occur at the same time, so inducing relaxation helps to counteract anxiety.

Steps in systematic desensitisation

1. Learning relaxation techniques - Patients are taught methods such as deep muscle relaxation.
2. Creating a fear hierarchy - Together with the therapist, the patient develops a list of fear-inducing situations, ranked from least to most frightening.
3. Gradual exposure with relaxation - Starting with the least feared item, the patient is exposed to the situation while using relaxation techniques. Exposure can be imagined or in vivo.
4. Progressing through the hierarchy - The patient moves to the next item only when they can handle the current one without anxiety.

Cognitive-behavioural therapy

Cognitive-behavioural therapy (CBT) is a psychological treatment that combines cognitive and behavioural elements to address anxiety and fear-related disorders. It assumes that fears stem from cognitive fear structures – mental frameworks of inaccurate beliefs about threats – which persist due to avoidance behaviours that prevent new, positive information from being integrated.

Key components of CBT

• Challenging irrational beliefs - Therapists help patients identify automatic negative thoughts and encourage them to evaluate evidence for and against these beliefs.
• Exposure to feared situations - Through controlled exposure, patients confront fears, allowing them to disconfirm inaccurate beliefs. This restructures the fear framework, typically within approximately 20 sessions.
• Homework assignments - Between sessions, patients practise skills like exposure tasks or thought challenging. They report back on experiences, which helps reinforce learning and track progress.

Applied tension for blood-injury-injection phobias

Blood-injury-injection (BII) phobias involve intense fear of blood, injuries, or medical procedures like injections, often leading to fainting due to a drop in blood pressure. Applied tension (AT) is a technique specifically designed to prevent fainting by raising blood pressure through muscle tensing.

How applied tension works

• Muscle tensing procedure - While sitting, the patient tenses muscles in the arms, torso, and legs simultaneously.
• Timing and repetition - Tension is held for 10–15 seconds, then released for 20–30 seconds. This cycle is repeated five times.
• Integration with other therapies - AT is often combined with CBT to address both fainting and fear, as CBT alone may not fully manage the physiological response of fainting in BII phobias.

Key study: Chapman and DeLapp (2013)

Chapman and DeLapp (2013) conducted a case study to explore the effectiveness of combining CBT with applied tension for treating BII phobias. The study highlighted how AT addresses fainting, which is linked to disgust responses and is less responsive to CBT alone.

Aim

To investigate whether applied tension could effectively reduce symptoms in a person with severe BII phobia, including fainting.

Participants

The participant was a 42-year-old male who had experienced severe BII symptoms for over two decades. He avoided medical settings like doctors and hospitals, had a family history of BII phobias, and had faced childhood bereavements that may have contributed to his condition.

Method

This was a case study design, using questionnaires and interviews to collect data. Variables measured included anxiety levels, fear, and specific BII symptoms through psychometric tests. The same tests were used before and after treatment to control for measurement consistency.

Procedure

• Baseline assessment - Initial data was gathered using psychometric tests to establish symptom levels.
• Treatment sessions - Nine sessions of CBT combined with AT were provided. This included psychoeducation, creating a ten-item fear hierarchy rated on the Subjective Units of Discomfort Scale (SUDS) from 0 to 100, and homework such as practising AT five times daily, completing graduated exposure tasks, and recording thoughts, feelings, and behaviours.
• Exposure exercises - Tasks progressed from watching blood test videos on YouTube, to a finger-prick blood test, observing blood donations, and finally booking and having a real blood test.
• Follow-up - Further assessments occurred at four, ten, and twelve months post-treatment.

Ethics

Anonymity was protected by referring to the participant as 'T'. Progression through the fear hierarchy was at T's own pace to minimise harm.

Results

SUDS scores showed reductions in anxiety during exposure tasks:

At the 12-month follow-up, symptom scores decreased significantly. For example, on the Blood-Injection Symptom Scale, T reported experiencing all 17 sensations before treatment but only 4 afterwards.

Conclusions

CBT combined with AT effectively reduces BII phobia symptoms, including fainting, leading to long-term improvements.

Evaluation

• Strengths - Quantitative data from SUDS scores allowed precise monitoring of changes within and between sessions. The detailed case history provides practical insights for therapists treating similar clients.
• Limitations - Self-reported SUDS scores may be influenced by social desirability bias or demand characteristics, reducing validity. Without a control group, it's unclear if improvements resulted from the treatment or other factors, such as natural symptom reduction over time.

Evaluating treatments for anxiety and fear-related disorders

Treatments for these disorders vary in effectiveness, with strengths and weaknesses depending on the approach and individual factors.

Issues and debates: Idiographic versus nomothetic approaches

In psychological research, the idiographic approach focuses on in-depth study of individuals to understand unique experiences, while the nomothetic approach seeks general laws through large-scale studies. The Chapman and DeLapp (2013) case study is idiographic, providing detailed insights into one person's BII phobia treatment with AT and CBT. It aims to highlight potential benefits for similar cases rather than making broad generalisations to all people with BII phobias or all therapists using these methods.