Anxiety disorders: phobias


“Anxiety disorder” refers to a disorder in which there is a general feeling of dread or apprehensiveness alongside various physiological reactions, such as: increased heart rate, sweating or muscle tension. The DSM-IV groups anxiety disorders into four categories: panic disorders, generalised anxiety, phobias, and obsessive-compulsive disorder.

The largest category of anxiety disorders is the phobia category. A phobia is a disorder in which extreme feelings of fear and anxiety are triggered by a specific stimulus.

The official diagnostic criteria is as follows:

  1. An intense, persistent, irrational fear of a specific object, person or situation.
  2. A disproportionate response that leads to avoidance of the specific stimulus.
  3. The fear is interfering with everyday life.


Phobias are further categorised into three main groups: social phobias (the fear of social situations), specific phobias (the four types are nature, animal, medical and situational) and agoraphobia (the fear of enclosed and inescapable spaces and places, not white men).

An example of a social phobia could be the fear of eating in front of other people or talking to a large crowd. A specific phobia, of a specific thing, could be the fear of injections or snakes.

A few fancy-named phobias:

  • Aviophobia (the fear of flying)
  • Coulrophobia (the fear of clowns)
  • Cynophobia (the fear of dogs)
  • Haemophobia (the fear of blood)
  • Pogonophobia (the fear of beards)
  • Tokophobia (the fear of pregnancy or childbirth)



The behavioural explanation of phobias has three main areas: classical conditioning, the two-process theory, and the social learning theory.

Classical conditioning: John Watson and Rosalie Rayner (1920):
Watson said that most emotional responses, like the fear of a certain stimulus, are learned through classical conditioning. Watson and Rayner experimented on a nine-month-old boy called Little Albert. They tested his reaction to different stimuli, including: a white rat, a rabbit, a monkey and several masks. They noted that Albert would end up crying if a hammer hit a steel bar behind his head.

When he was just over 11-months-old, the white rat would be shown to him along with the sound of the hammer. This was done seven times over the following seven weeks, and Albert cried every time it happened. The final result was that he showed signs of fear simply by looking at a white rat. He was conditioned into fearing the white rat because he had made an association that linked the white rat to the unpleasant hammer sound.

Although ethically very dubious, this study showed that phobias could be learned by classical conditioning. Over the next few weeks and months, Albert was continuously observed. 10 days after the conditioning, his fear of the white rat was much less noticeable but it was still visible even after a month.

John Watson, an American psychologist known for his behaviourist studies, with his research assistant/student Rosalie Rayner (who he had a bit of an affair with and ended up marrying!)

Orval Hobart Mowrer:
Mowrer proposed a two-process theory: the first stage had classical conditioning (when developing a phobia) and the second stage had operant conditioning (receiving positive and negative reinforcers). So once the phobia developed in the first stage, it would be maintained by reinforcers. Generally, the avoidance of the stimulus (e.g. big dogs) creates feelings of fear, distress or anxiety (the reinforcement).

Susan Mineka:
Mineka showed that the social learning theory plays a part in the development of phobias, meaning that fear can be learned by imitation. She experimented and found that some monkeys developed a phobia of snakes simply by watching another monkey experience fear in the presence of snakes.


The psychoanalytic explanations of phobias revolve around Freud and his theory of the “id, ego and superego”.

Sigmund Freud (1909):
Freud interpreted phobias through his theory of “ego defence mechanisms”. He said that any thoughts or ideas of the id that produced anxiety were repressed and locked in a person’s unconscious mind. Here, the anxiety would be displaced and attributed to a different object that becomes the stimulus for a phobia. This new object can be easily avoided by the individual. If you remember the case study of Little Hans (remind yourself here), then you can recall how his fear of castration was displaced onto horses, thus resulting in his horse phobia.


There is some evidence for a genetic explanation of specific phobias. It is important to realise that people do not inherit a specific gene for an illness, they simply inherit the vulnerability to it.

Lars-Göran Öst (1992):
Öst found that people with a phobia of blood injuries had 60% of first-degree relatives who also suffered from a specific blood-related phobia.


According to the cognitive model, our emotions are the result of interpretations we make of our experiences in accordance with our existing schemas. People with phobias, therefore, are likely to do the following:

  • Exaggerate negative consequences
  • Underestimate their own coping abilities
  • Show “catastrophic misinterpretation”

Peter DiNardo (1988):
DiNardo and his colleagues studied a group of people with dog-related phobias and found a matched-design group who did not suffer from that phobia. They found that over 50% of people with dog phobias could recall being bitten or having a frightening past experience with a dog. However, 50% of the group with no dog phobia also had memories of being bitten by dogs and yet had not developed any anxiety about seeing dogs in the future. This shows that not everyone who is exposed to conditioning would end up developing a phobia, and it may lean more towards our thought processes about the experience.


Systematic densensitisation

This is a behavioural therapy based on the principles of classical conditioning. It aims to remove the “fear response” to a phobia and replace this fear with a “relaxation response”. It uses counter-conditioning. Systematic desensitisation is done by basically developing a hierarchy of fear that involves the original conditioned stimulus.

Joseph Wolpe (1958):
Wolpe developed this treatment of phobias in the late 1950s. The patient starts at the “least unpleasant” step of the hierarchy of fear and systematically works their way up to the “most unpleasant” only after they have learned to be relaxed in response to each rank. For example: a small, stationary, plastic spider sitting five meters away may be on the “least pleasant” rank for a person with a spider phobia but a large, moving, creepy-freaky-Harry-Potter-style spider crawling towards the patient would probably be the “most unpleasant”.

That’s what he thinks!

The patient would repeatedly imagine or really be confronted by the threatening situation until anxiety reduces. When this happens, it means they are becoming desensitised to the stimulus. Counter-conditioning is being carried out; it is just using one association to counter a different association.

The patient may also be given techniques for relaxation. However, some studies have shown that neither relaxation techniques nor hierarchies of fear are needed; the only vital factor is exposure to the stimulus.

Exposure can be of two types:

  • In-vitro exposure (patient imagines experiencing the stimulus)
  • In-vivo exposure (patient really experiences the stimulus)

Wolpe summarised his treatment in three steps:

  1. The client is trained in deep relaxation techniques.
  2. The client and therapist construct a list of anxiety-inducing stimuli in a hierarchy.
  3. Feared stimuli are paired with relaxation until they can be tolerated by the client.


Flooding is a behavioural treatment for phobias that is based on classical conditioning. It is also called “exposure therapy”.

Flooding was invented by Thomas Stampfl in 1967. Compared to systematic desensitisation, flooding is much faster. However, it is also more traumatic and usually less efficient. It works by exposing patients to their painful memories and aims to reintegrate repressed emotions with current awareness.

The patient is “flooded” with and immersed into their phobia with no way of escaping until they reach the point where it stops being distressing. Flooding uses in-vivo exposure. For example: a patient with a phobia of cars could be driven around for hours. Successful flooding would result in initial hysteria or distress but would eventually turn into ease and relaxation because the irrationality of the phobia would be seen by the patient, helping them to overcome it.

Applied tension

Applied tension is a behavioural therapy for blood-related phobias. Most people with a phobia of blood feel disgust or nausea rather than actual fear. In applied tension, the patient learns to quickly spot signs of decreasing blood pressure and counter it by using coping skills that involve tensing their muscles to increase their blood pressure. Applied tension is as effective as other treatments and can be conducted in half the general time. Clinically, it is seen as the leading treatment for blood phobia.

Lars-Göran Öst (1989):
Öst invented the applied tension technique. He gathered 30 patients with phobias of blood, wounds and injuries. He treated them all individually, using applied tension and applied relaxation. The patients were then evaluated by self-reporting, behavioural measures and physiological measures both before and after receiving treatment as well as six months later. All patients improved significantly on 11 out of 12 measures and maintained their overall progress, making this a highly successful form of treatment.

Cognitive-behavioural therapy

CBT addresses negative patterns and distortions in the way individuals look at the world and themselves. It is the most popular treatment for anxiety disorders because it generally shows positive results when treating things like panic disorders and phobias.

Lars-Göran Öst and Bengt Westling (1995):
Öst and Westling wanted to compare the effects of CBT and applied relaxation in the treatment of panic disorders. They conducted a longitudinal (long-term) study with 38 patients. Before treatment, the patients were assessed on questionnaires. They were then given 12 weeks of treatment for around an hour per week.

Applied relaxation was used to identify the cause of panic attacks, and the releasing of muscle tension. CBT was first used to identify the misinterpretation of physical symptoms and then to produce an alternative cognition in response. For example: rather than panicking in stressful situations, the patient would calm themselves down by thinking logically.

All patients were then assessed with questionnaires after being treated, as well as after a one-year follow-up.

Applied relaxation had a 65% success rate after treatment and 82% at the follow-up. CBT had a 74% success rate after treatment and 89% at the follow-up. The results were not significantly different but showed that both techniques were very similar in their success and effectiveness.