1.4 Anxiety disorders and fear-related disorders
- Syllabus
- 9990–2028–2029
- Topic
- 1.4
- Level
- A2
Learning objectives
1.4.1Anxiety criteria• 1.4.1 Diagnostic criteria for anxiety disorders and fear-related disorders- diagnostic criteria (ICD-11) of anxiety disorders and fear-related disorders:- - generalised anxiety disorder- - agoraphobia- - specific phobia (blood-injection-injury).- measures of anxiety and fear-related disorders:- - Generalised Anxiety Disorder assessment (GAD-7).- - the Blood-injection Phobia Inventory (BIPI), including a study, e.g. Mas et al. (2010).- Relevant issues and debates and methodology for this topic include: questionnaires, psychometrics, subjective and objective data, validity, reliability.1.4.2Fear-related explanations• 1.4.2 Explanations of fear-related disorders- biological explanation: genetic, including a study, e.g. Öst (1992).- psychological explanations:- - behavioural (classical conditioning), including a study, e.g. Watson and Rayner (1920) 'Little Albert'- - psychodynamic, including a study, e.g. Freud (1909) 'Little Hans'.- Relevant issues and debates and methodology for this topic include: nature versus nurture, determinism versus free-will, case studies, longitudinal studies, validity.1.4.3Anxiety treatments• 1.4.3 Treatment and management of anxiety disorders and fear-related disorders- behavioural therapy: systematic desensitisation applied to any fear-related disorder.- psychological therapy (exemplified by the following key study):- - cognitive-behavioural therapy (CBT)- - applied tension focusing on treating blood-injection-injury phobia.- Key study on treating blood-injection-injury phobia using cognitive-behavioural therapy (CBT) with applied tension: Chapman and DeLapp (2013).- Relevant issues and debates and methodology for this topic include: idiographic versus nomothetic, case studies, self-reports, longitudinal studies, generalisations.
Separate diagnostic pattern from GAD-7 and BIPI measurement
| Disorder | Required pattern | Distinguishing application |
|---|---|---|
| Generalised anxiety disorder | Persistent, excessive anxiety/worry across several everyday domains, difficult to control, with associated tension/arousal symptoms and impairment | Not a brief response to one event or one specific feared object; consider duration, breadth, distress, function and alternatives |
| Agoraphobia | Marked fear/anxiety across situations where escape or help may feel difficult, followed by avoidance/endurance and impairment | Context and culture matter: staying home may reflect danger or norms rather than disproportionate fear |
| Specific phobia: blood-injection-injury | Marked, disproportionate fear/avoidance of blood, injections or injury causing distress/impairment | May include a distinctive diphasic response and faintness; establish persistence and functional effect rather than diagnosing from dislike alone |
| GAD-7 | Exact use | Boundary |
|---|---|---|
| Seven symptoms over the previous two weeks | Nervous/on edge; uncontrolled worry; excessive worry; trouble relaxing; restlessness; irritability; fear something awful may happen | Frequency is not severity, cause or life impact |
| Four response levels | 0 not at all, 1 several days, 2 more than half the days, 3 nearly every day | Self-report depends on recall, insight and honest disclosure |
| Total 0–21 | Quick screening and repeated monitoring during/after therapy | Screening supports referral/monitoring; it cannot provide full diagnosis alone |
| Mas et al. (2010) BIPI development | Evidence |
|---|---|
| Purpose/sample | Build a Spanish-population blood/injection phobia measure; 174 Spanish-speaking participants |
| Instrument | Self-administered inventory covering 18 blood-related situations/stimuli and 27 phobic responses on four-point Likert-type ratings |
| Reliability | Cronbach's alpha .98 indicates very high internal consistency |
| Validity/structure | Good concurrent, convergent and discriminant validity; one factor explained 76% of stimulus-content and 74% of phobic-response variance |
| Boundary | Strong psychometrics in this sample do not remove self-report bias or guarantee cross-cultural equivalence |
A valid assessment triangulates: exact ICD-11 pattern and impairment; standardised quantitative screening; qualitative clinical interview; and, only when safe and ethical, overt controlled observation. Reliability means consistency, not truth. Numerical scoring is standardised, but the experience and report remain subjective.
GAD-7 is a broad anxiety screening/monitoring measure; BIPI is specific to blood/injection stimuli and responses. Neither is a self-diagnosis tool. Real diagnosis, fainting risk and treatment decisions require qualified clinical assessment.
Genetic vulnerability, conditioned fear and unconscious displacement make different causal claims
| Explanation | Mechanism | Study anchor |
|---|---|---|
| Biological/genetic | Inherited vulnerability may raise probability of intense fear and physiological fainting response | Öst (1992) family-history and behavioural/physiological comparison |
| Behavioural | Neutral stimulus (NS) paired with fear-producing unconditioned stimulus (UCS) produces UCR; NS becomes CS and evokes conditioned fear response (CR); generalisation spreads fear to similar stimuli | Watson and Rayner (1920), Little Albert |
| Psychodynamic | Unacceptable childhood id–ego conflict is repressed; anxiety is displaced onto a safer symbolic object, producing phobia | Freud (1909), Little Hans |
| Öst (1992) | Exact evidence and inference |
|---|---|
| Groups | 81 blood-phobic and 59 injection-phobic patients meeting diagnostic criteria |
| Methods | Clinical/background comparison with questionnaire/interview and behavioural/physiological tests |
| Findings | Same phobia in a first-degree relative: 61% blood group versus 29% injection group; feared fainting: 77% versus 48% |
| Conclusion | Family clustering and physiological response support inherited vulnerability, but shared family learning and retrospective self-report prevent a genes-only causal conclusion |
| Study | Mechanism reconstruction | Validity boundary |
|---|---|---|
| Little Albert | White rat NS + loud iron-bar noise UCS → crying UCR; rat became CS → crying/fear CR; fear generalised to similar furry/white objects | Observable change supports conditioning, but deliberate infant distress, artificial repeated pairing, one case and incomplete deconditioning limit ethics/ecological validity/generalisation |
| Little Hans | Horse fear interpreted as displaced fear of father during phallic-stage Oedipal conflict; horse features symbolised father | Longitudinal letters gave rich in-context data, but father/Freud interpretation, one child, unfalsifiable unconscious constructs and an actual frightening horse event weaken causal validity |
| Debate | Evaluation |
|---|---|
| Nature–nurture | Genetic is nature-oriented; conditioning is nurture; psychodynamic combines universal stages with individual childhood experience; interaction best fits mixed evidence |
| Determinism–free will | Genes, learned associations and unconscious conflict constrain behaviour, though treatment and chosen exposure allow agency |
| Case/longitudinal methods | Repeated observation shows development and reduces distant recall, but is slow, vulnerable to attrition/relationship bias and hard to generalise |
| Scientific validity | Conditioning variables are observable; genetic family association is correlational; unconscious symbolism is difficult to test or falsify |
Öst supports familial vulnerability, not inheritance of a single phobia gene. Albert shows one acquired fear under unusual conditions, not that all phobias require repeated trauma. Hans is evidence interpreted through Freud's theory, not direct measurement of unconscious conflict.
Match graded fear reduction and applied tension to different treatment targets
| Treatment | Ordered procedure | Main target |
|---|---|---|
| Systematic desensitisation | Teach relaxation → collaboratively build least-to-most fear hierarchy → expose at lowest step while relaxed → progress only when manageable → repeat across sessions | Reciprocal inhibition and gradual exposure weaken conditioned anxiety/avoidance |
| CBT for BII phobia | Psychoeducation → identify/test faulty predictions → balanced alternatives → SUDS-rated graduated in-vivo exposure and between-session practice | Fear meaning, expectancy, avoidance and behavioural confidence |
| Applied tension | Tense large arm/leg/torso muscles about 10–15 seconds, return toward normal for about 20–30 seconds, repeat/practise and use when faintness cues appear | Raises blood pressure to counter the BII diphasic/vasovagal fainting response |
Application must be contextual. Build hierarchy steps from the learner's exact trigger, state the relaxation or muscle-tension action at each step, explain the mechanism, and predict observable change. Applied tension is not ordinary relaxation: relaxing alone may worsen protection against fainting for some BII presentations.
| Chapman & DeLapp (2013), participant T | Evidence |
|---|---|
| Design | Idiographic adult case study; nine-session manualised CBT combining psychoeducation, cognitive restructuring, applied muscle tension and graduated in-vivo exposure |
| Measurement | Personal 0–100 SUDS hierarchy plus standardised anxiety/depression/BII and quality-of-life measures; objective/quantitative and subjective/qualitative evidence |
| Hierarchy examples | Blood pressure in pharmacy/by nurse/self, blood sugar self/by wife, phlebotomy live/video, tourniquet touching veins, physical/stress test |
| Outcome | At phlebotomy SUDS began about 40/100 then fell to nothing with minimal applied tension; follow-ups at 4, 10 and 12 months reported no fear/terror to medical stimuli |
| Inference | Detailed longitudinal change supports feasibility for T; combined components and one participant prevent isolating which element worked or generalising a universal effect |
| Lens | Evaluation |
|---|---|
| Idiographic–nomothetic | Personal hierarchy/SUDS fit T; manual and standard scales aid replication/comparison |
| Case/longitudinal | Nine sessions and 12-month follow-up show maintenance in one person; self-report, therapist expectancy and no control condition limit causality |
| Generalisation | CBT/exposure principles may transfer; applied tension specifically targets fainting-prone BII response, not every anxiety disorder |
| Access/ethics | Gradual collaboration supports consent/control, but cost, time, distress and dropout remain; exposure must be safe and qualified |
| Individual–situational | Treatment changes responses within feared situations while tailoring cognition, physiology and hierarchy to the individual |
Systematic desensitisation pairs graded exposure with relaxation; applied tension contracts muscles to raise blood pressure; CBT also changes predictions and avoidance. Do not begin with the most feared unsafe situation, and do not treat a single case as universal clinical advice.