Specific Phobia

Phobic disorders are characterized by intense fears of a circumscribed stimulus. In the case of specific phobia, the fear, averson, and avoidance tend to be of things in the environment; for example, storms, animals or insects, heights, and the like.

Overview and Presentation

With specific phobia, the stimulus that causes anxiety may be an object or situation. Exposure to these things produces intense fear, anxiety, or feelings of aversion, leading a person to escape the situation or endure it with intense discomfort. The response is tantamount to a panic attack; however, with a phobia, the attack is in response to a specific stimulus, and is not spontaneous (although panic disorder may be superimposed on a long-term course of phobia). However, like panic, anticipatory anxiety and avoidance of feared situations may lead the person to modify his or her lifestyle.

Specific phobias are common and often do not affect a person’s life in a major way. For example, a person with a spider phobia may avoid his attic or basement, but may not otherwise be seriously affected, unless exposed to an actual spider. In fact, a majority of affected persons never seek treatment. However, the person may have a substantial impairment. An example would be a person who fears enclosed spaces and completely avoids elevators. This may have an impact on their vocational choice or attainment. The fear of enclosed spaces is called claustrophobia. Other common specific phobias are listed in Table X-1.

Diagnostic Criteria

Diagnostically, this disorder differentiates from other anxiety disorders primarily because of a unique fear arising in very specific circumstances. In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging behavior. Confronting the phobic stimulus results in a strong sense of dread and often a desire to flee, and the person may experience physiological and somatic symptoms that are found in other anxiety disorders. Autonomic arousal may result in panic-like symptoms, such as trembling, shortness of breath, sweating, or tachycardia. Certain phobias (e.g., blood phobia) have been noted to have a sharp fall in blood pressure leading to dizziness and possible syncope (a “vasovagal” response). The fear or anxiety is clearly out of proportion to the actual danger posed by the object or situation. The diagnosis should be sensitive to the sociocultural context; the anxiety or fear should be excessive as compared to other members of the sociocultural group.

Epidemiology

Specific phobia is one of the most common disorders and may afflict up to 25% of the population with mild symptoms, although specific phobias meeting full diagnostic criteria have a 12- month prevalence of 7.1% and lifetime prevalence of 9.4%. There is increased risk of having this diagnosis in females and persons with low income. Onset of symptoms may occur in childhood, and commonly before adult life. Little is still known about the course of untreated specific phobias because phobias may resolve spontaneously or people learn to cope with these stressors, and may never come to attention.

Etiology

Little is known about the development of specific phobia from a biological or genetic standpoint. Little research has been done to isolate specific factors in the development of this disorder, both biological and otherwise. Observers have noted that specific phobia runs in families, and there may be a predisposition for family members fo an afflicted patient to develop a phobia of the same type. As well, people with other anxiety disorders such as panic or social anxiety disorder may be at increased risk. There is research to suggest that evolutionarily relevant fears can occur without being learned by specific experiences. Phobias generally do not occur as a result of a traumatic event. Although traumas may lead to phobic avoidance, this usually occurs in the context of traumatic stress disorders. However, prior abuse or similar early traumas do not appear to predispose to phobias.

Specific phobia involves panic-like responses, and is though to involve the same pathways as panic disorder. Moreover, unlike spontaneously occurring panic, the phobic stimulus has to be first recognized, which then activates the neural response. Therefore, cortical activity is involved, as well as the amygdale and hippocampus. However, ultimately, midbrain structures, particularly the locus ceruleus, are likely to be involved.

Differential Diagnosis and Comorbidity

Comorbidity of other anxiety and depressive disorders is common in specific phobia, which may require treatment. However, care should be taken with regard to certain disorders. For example, people with psychotic disorders such as schizophrenia may have fears of circumscribed objects or situations. However, this kind of fear involves delusional thinking. As well, social anxiety disorder may result in fear and avoidance of certain circumstances that involve exposure to scrutiny by others, as described in greater detail below. With obsessive-compulsive disorder (OCD), the obsessional thinking or compulsive behavior may be stimulated by specific places or things, which then are avoided. As an example, people with OCD often avoid public restrooms because of a fear of contamination. Finally, simple phobias can cause extreme autonomic arousal similar to panic disorder, and may be mistaken for panic attacks. However, the recurring presence of specific stimuli will help differentiate between these two disorders. In fact, specific phobia is quite unlike panic in certain ways. People with phobias usually know precisely what they fear. Further, they seldom, if ever, fear becoming psychotic or having some serious medical illness such as a myocardial infarction. Specific phobias are typically easily recognized.

Treatment

No medications are indicated for the treatment of specific phobia. Drugs such as benzodiazepines may ameliorate symptoms, when the exposure can be anticipated. For example, people with a phobic reaction to blood may have high anxiety when blood is drawn. Likewise, people with claustrophobia may not be able to endure an MRI scan, because of being in an enclosed space. In these kinds of situations, a benzodiazepine can be used on an as-needed basis.

However, the treatment of choice for specific phobia is behavioral therapy, particularly exposure and desensitization. This kind of treatment often involves initial relaxation training, which then is followed by progressive exposure to the phobic stimulus. As an example, people with insect phobias might begin their treatment with looking at pictures of feared insects. They can progress to a plastic insect, and then, with time, to the actual insect. When done repeatedly, the fear is usually extinguished, and the phobia is no longer a problem.

Course and Prognosis

Phobias can develop throughout the life span. Phobias that develop in childhood may spontaneously remit later in life, although persistence is most common. As data suggests, many persons suffering from phobias will not present for treatment specifically for their phobia. Poorer outcomes have been associated with persons suffering from multiple phobias and lack of motivation or participation in therapy.

Since cognitive science Opens in new window has taken on board this commonsense view of the mind, an important question is how such a relationship to a proposition can be implemented.

The representation theory of mind (RTM; Field, 1978; Fodor, 1978) assumes that a propositional attitude consists in holding a representation of the proposition and that this representation plays a certain functional role in the economy of mental states. This can be best illustrated with the two core concepts: belief and desire.

These are core concepts, since knowing what someone believes (thinks) to be the case (e.g., Max thinking the chocolate is in the cupboard and thinking that going there will get the chocolate into his possession) and what that person desires (wants) (e.g., Max wanting the chocolate to be in his possession) allows us to make a behavioral prediction that Max will approach the cupboard. This kind of inference is known since Aristotle as the practical syllogism.

Searle (1983, after Anscombe, 1957) points out that these two states are mirror images in terms of causal direction and direction of fit. The function of a belief is to be caused by reality and the believed proposition should match reality.

The function of desire (want) is to cause a change in the world (mind to world causation) so that the world conforms to the desired proposition (world should fit mind)—for example, if Max wants the chocolate to be in the cupboard, then this desire should cause action leading to a change of the chocolate’s location such that it conforms to what Max desires.

This trivial-sounding example does highlight the important distinctions.

Three Important Distinctions

1. First vs. Third Person

One important distinction is between first-person and third-person attribution of mental states. A third-person attribution is an attribution to another person and a first-person attribution is one to myself.

The observer can capture this difference between her own and Max’s subjective view by the second-order attribution that Max thinks he knows where the chocolate is. This is useful to keep in mind when it comes to false memories. Since a memory can only be a recollection of something that actually occurred, a false memory is not a memory by third-person attribution, although it is by first-person attribution.

2. Sense and Reference

A related second point has to do with Frege’s (1892/1960) distinction between sense and reference. Since mental states involve representations, they connect us to objects and events in the real (or a possible) world.

Famously, Oedipus knew and married Iocaste (referent: a particular person), but he did not know or marry her as his mother but as an unrelated queen (sense: how Iocaste was presented to Oedipus’ mind).

Thus, in third-person parlance we can say that Oedipus married his mother if we use the expression “his mother” to pick out (refer to) the individual whom he married without implying that he knew Iocaste under that description. In first-person description of the event Oedipus would not have used the descriptor “my mother.”

These distinctions are useful to keep in mind when discussing infants’ ability to remember particular events: Whenever a memory trace of a unique event can be demonstrated then one can conclude (in first-person parlance) as a particular event—that is, that the infant makes cognitive distinctions that represent that event as a particular event.

3. Having vs. Representing a Mental State

The third important distinction is that between being in a mental state (or having an attitude) and representing that mental state.

For understanding or knowing that a person is in a mental state, or to reflect on one’s own mental states, one has to be able to represent that state. In order to be able to represent a state, one needs a concept of that state—that is, a rich enough theory of mind.

The study of how children acquire the requisite theory of mind is therefore essential for our understanding of how children come to understand memory. Furthermore, since some memorial states are reflective or self-referential, children need a theory of mind for being in such states or having such memories.

Why We Need a Theory of Mind for Memory

We probably do not need a theory of mind for implicit (nondeclarative Opens in new window) memory, but for explicit (declarative Opens in new window) memory we do, since “explicit memory is revealed when performance on a task requires conscious recollection of previous experiences.” (Schacter, 1987).

To be conscious of a fact one requires to be also aware of the state with which one beholds that fact. The higher-order-thought theories of consciousness make this their core claim (Armstrong, 1980; Rosenthal, 1986).

To be conscious of this state of affairs means, according to theory, that one entertains a second-order thought about the seeing—that is, the second-order thought represents the first-order seeing.

A weaker version does not require that one has to entertain the second-order thought, but only that one has to have the potential for having the second-order thought (Carruthers, 1996). That some such condition must be true can be seen from the following consideration:

The important point of these conceptual analyses is that to be conscious of some fact requires some minimal concept of knowledge or of some perceptual state like seeing.

Unfortunately, there is no clear evidence when children understand a minimal state of this sort. There is some evidence of understanding (mother’s) emotional reactions and seeing (direction of gaze) in the first year of life (see Perner, 1991, chap. 6; Baldwin & Moses, 1996; Gopnik & Meltzoff, 1997, for summaries and discussion of problems of interpretation).

There is also some recent evidence that between 8 and 12 months children might be inferring people’s intentions to grasp an object from where that person looks (Spelke, Philips, & Woodward, 1995) and even between 5 to 9 months from how a person touches an object (seemingly intentional or accidentally).

And by 18 months (where children’s understanding of mental phenomena seems to flourish in general) children imitate people’s intended actions even when they observe a failed attempt (Meltzoff, 1955a) and they understand differences in preferences (e.g., that someone else can prefer cauliflower over biscuits, Repacholi & Gopnik, 1997).

Evidence that children distinguish their knowledge from ignorance is available at a relatively late age. Povinelli, Perilloux, and Bierschwale (1993) asked children to look for a sticker under one of three cups.

Children were first trained to look under the cup at which the experimenter had pointed. After some training even the youngest were able to do this.

When asked to look without the experimenter pointing, an interesting developmental difference emerged. Children older than 2 years and 4 months acted without hesitation when they knew which the cup the sticker was under, but hesitated noticeably when—in the absence of the experimenter’s poining—they had to guess where it was.

Interestingly this is also the age at which children start using the phrase “I don’t know” (Shatz, Wellman, & Silber, 1983). In contrast, children younger than that showed no comparable difference in reaction time. This may indicate that young 2-year-olds do not yet reflect on what they do and do not know.

So, theory of mind research is not yet able to give a guideline for when infants might develop explicit, conscious memories. Memory development may help out on this point.

Meltzoff (1985, 1995b) demonstrated that 14-month-old infants can reenact a past event (e.g., they imitate the experimenter leaning forward to touch a panel with forehead so that panel lights up) after several months. Recently this has been demonstrated in 11-month-olds with a delay of 3 months.

Since this is achieved from a brief observational period and does not require prolonged learning, and since patients with amnesia cannot do this (McDonough, Mandler, KcKee, & Squire, 1995), it is tempting to conclude that such enactment demonstrates explicit, conscious memory.

One should, though, keep in mind that delayed imitation that is based on a single event (third-person view) is not to be equated with a memory (knowledge) of that event as a single, past event (first-person view).