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Chapter 5
Anxiety Disorders
Slides & Handouts by Karen Clay Rhines, Ph.D.
Seton Hall University
Anxiety
 What distinguishes fear from anxiety?
• Fear is a state of immediate alarm in response to a
serious, known threat to one’s well-being
• Anxiety is a state of alarm in response to a vague
sense of threat or danger
• Both have the same physiological features:
increase in respiration, perspiration, muscle
tension, etc.
Slide 2
Anxiety
 Is the fear/anxiety response useful/adaptive?
• Yes, when the fight or flight response is
protective
• No, when it is triggered by “inappropriate”
situations, or when it is too severe or long-lasting,
this response can be disabling
• Can lead to the development of anxiety disorders
Slide 3
Anxiety Disorders
 Most common mental disorders in the U.S.
• In any given year, 19% of the adult population in
the U.S. experience one or another of the six
DSM-IV anxiety disorders
• Most individuals with one anxiety disorder suffer from
a second as well
 Anxiety disorders cost $42 billion each year
in health care, lost wages, and lost
productivity
Slide 4
Anxiety Disorders
 Six disorders:
• Generalized anxiety disorder (GAD)
• Phobias
• Panic disorder
• Obsessive-compulsive disorder (OCD)
• Acute stress disorder
• Post-traumatic stress disorder (PTSD)
Slide 5
Generalized Anxiety Disorder
(GAD)
 Characterized by excessive anxiety under most
circumstances and worry about practically anything
• Vague, intense concerns and fearfulness
• Often called “free-floating” anxiety
• “Danger” not a factor
 Symptoms include restlessness, easy fatigue,
irritability, muscle tension, and/or sleep disturbance
• Symptoms last at least six months
Slide 6
Generalized Anxiety Disorder
(GAD)
 Symptoms are often misunderstood by others
• Sufferers are accused of “looking for” worries
 The disorder is common in Western society
• Affects ~4% of U.S. and ~3% of Britain’s population
 Usually first appears in childhood or adolescence
 Women are diagnosed more often than men by 2:1
ratio
 Various theories have been offered to explain the
development of the disorder…
Slide 7
GAD: The Sociocultural Perspective
 GAD is most likely to develop in people faced with
social conditions that are truly dangerous
• Research supports this theory (example: Three Mile Island
in 1979)
 One of the most powerful forms of societal stress is
poverty
• Why? Run-down communities, higher crime rates, fewer
educational and job opportunities, and greater risk for
health problems
• As would be predicted by the model, rates of GAD are
higher in lower SES groups
Slide 8
GAD: The Sociocultural Perspective
 Since race is closely tied to income and job
opportunities in the U.S., it is also tied to the
prevalence of GAD
• In any given year, about 6% of African
Americans vs. 3.5% of Caucasians suffer from
GAD
• African American women have highest rates (6.6%)
Slide 9
GAD: The Sociocultural Perspective
 Although poverty and other social pressures
may create a climate for GAD, other factors
are clearly at work
• How do we know this?
• Most people living in dangerous environments do not
develop GAD
• Other models attempt to explain why some people
develop the disorder and others do not…
Slide 10
GAD: The Psychodynamic Perspective
 Freud believed that all children experience anxiety
• Realistic anxiety when faced with actual danger
• Neurotic anxiety when prevented from expressing id
impulses
• Moral anxiety when punished for expressing id impulses
 One can use ego defense mechanisms to control
these forms of anxiety, but when they don’t
work…GAD develops!
Slide 11
GAD: The Psychodynamic Perspective
 Some research does support the psychodynamic
perspective:
• People use defense mechanisms (especially repression)
when faced with danger
• People with GAD are particularly likely to use defense
mechanisms
• Children who were severely punished for expressing id
impulses have higher levels of anxiety later in life
 Are these results “proof” of the model’s validity?
Slide 12
GAD: The Psychodynamic Perspective
 Not necessarily; there are alternative
explanations of the data:
• Discomfort with painful memories or “forgetting” in
therapy is not necessarily defensive
• Non-anxious people faced with threats may use
repression
• Some data contradict the model
• Many (if not most) GAD clients report normal
childhood upbringings
Slide 13
GAD: The Psychodynamic Perspective
 Psychodynamic therapies
• Use same general techniques for treating all
dysfunction
• Free association
• Therapist interpretation
• Specific treatments for GAD
• Freudians: focus less on fear and more on control of id
• Object-relations: help patients identify and settle early
relationship conflicts
Slide 14
GAD: The Psychodynamic Perspective
 Psychodynamic therapies
• Overall, controlled research has not consistently
shown psychodynamic approaches to be helpful
in treating cases of GAD
• Short-term dynamic therapy may be beneficial in some
cases
Slide 15
GAD: The Humanistic Perspective
 Theorists propose that GAD, like other
psychological disorders, arises when people stop
looking at themselves honestly and acceptingly
 This view is best illustrated by Carl Rogers’s
explanation:
• Lack of “unconditional positive regard” in childhood
leads to “conditions of worth” (harsh self-standards)
• These threatening self-judgments break through and cause
anxiety, setting the stage for GAD to develop
Slide 16
GAD: The Humanistic Perspective
 Therapy based on this model is “client-centered” and
focuses on creating an accepting environment where
clients can “experience” themselves
• Although case reports have been positive, controlled
studies have only sometimes found client-centered
therapy to be more effective than placebo or no therapy
• Only limited support has been found for Rogers’s
explanation of causal factors
Slide 17
GAD: The Cognitive Perspective
 Theorists believe that psychological problems
are caused by maladaptive and dysfunctional
thinking
 Since GAD is characterized by excessive
worry (cognition), this model is a good
start…
Slide 18
GAD: The Cognitive Perspective
 Theory: GAD is caused by maladaptive assumptions
• Albert Ellis identified basic irrational assumptions:
• It is a necessity for humans to be loved by everyone
• It is catastrophic when things are not as one wants them
• If something is dangerous, a person should be terribly concerned
and dwell on the possibility that it will occur
• One should be competent in all domains to be a worthwhile
person
• When these assumptions are applied to everyday life,
GAD may develop
Slide 19
GAD: The Cognitive Perspective
 Aaron Beck is another cognitive theorist
• Those with GAD hold unrealistic silent
assumptions that imply imminent danger:
• Any strange situation is dangerous
• A situation/person is unsafe until proven safe
• It is best to assume the worst
• My security depends on anticipating and preparing
myself at all times for any possible danger
Slide 20
GAD: The Cognitive Perspective
 Research supports the presence of these types
of assumptions in GAD
• Also shows that people with GAD pay unusually
close attention to threatening cues
Slide 21
GAD: The Cognitive Perspective
 What kinds of people are likely to have
exaggerated expectations of danger?
• Those whose lives have been filled with
unpredictable negative events
• To avoid being “blindsided,” they try to predict events;
they look everywhere for danger (and therefore see
danger everywhere)
• Theory still under investigation
Slide 22
GAD: The Cognitive Perspective
 Two kinds of cognitive therapy:
• Changing maladaptive assumptions
• Based on the work of Ellis and Beck
• Teaching coping skills for use during stressful
situations
Slide 23
GAD: The Cognitive Perspective
 Cognitive therapies
• Changing maladaptive assumptions
• Ellis’s rational-emotive therapy (RET)
• Point out irrational assumptions
• Suggest more appropriate assumptions
• Assign related homework
• Limited research, but findings are positive
• Beck’s cognitive therapy
• Similar to his depression treatment (see Chapter 8)
• Shown to be somewhat helpful in reducing anxiety to
tolerable levels
Slide 24
GAD: The Cognitive Perspective
 Cognitive therapies
• Teaching clients to cope
• Meichenbaum’s self-instruction (stress inoculation)
training
• Teach self-coping statements to apply during four stages of a
stressful situation:
• Preparing for stressor
• Confronting and handling stressor
• Coping with feeling overwhelmed
• Reinforcing with self-statements
Slide 25
GAD: The Cognitive Perspective
 Cognitive therapies
• Teaching clients to cope
• Shown to be of modest help for GAD and moderate
help with situational and more mild anxiety
• Best when used in combination with other treatments
Slide 26
GAD: The Biological Perspective
 Theory holds that GAD is caused by
biological factors
• Supported by family pedigree studies
• Blood relatives more likely to have GAD (~15%)
compared to general population (~4%)
• The closer the relative, the greater the likelihood
• Issue of shared environment
Slide 27
GAD: The Biological Perspective
 GABA inactivity
• 1950s – Benzodiazepines (Valium, Xanax) found
to reduce anxiety
• Why?
• Neurons have specific receptors (lock and key)
• Benzodiazepine receptors ordinarily receive gammaaminobutyric acid (GABA, a common NT in the brain)
• GABA is an inhibitory messenger; when received, it causes a
neuron to STOP firing
Slide 28
GAD: The Biological Perspective
 In the normal fear reaction:
• Key neurons fire more rapidly, creating a general state of
excitability experienced as fear or anxiety
• A feedback system is triggered; brain and body activities
work to reduce excitability
• Some neurons release GABA to inhibit neuron firing, thereby
reducing experience of fear or anxiety
• Problems with the feedback system are believed to cause
GAD
• Possible reasons: GABA too low, too few receptors, ineffective
receptors
Slide 29
GAD: The Biological Perspective
 Promising (but problematic) explanation
• Other NTs also bind to GABA receptors
• Research conducted on lab animals raises
question: is “fear” really fear?
• Issue of causal relationships
• Do physiological events CAUSE anxiety? How can we
know? What are alternative explanations?
Slide 30
GAD: The Biological Perspective
 Biological treatments
• Antianxiety drugs
• Pre-1950s: barbiturates (sedative-hypnotics)
• Post-1950s: benzodiazepines
• Provide temporary, modest relief
• Rebound anxiety with withdrawal and cessation of use
• Physical dependence is possible
• Undesirable effects (drowsiness, etc.)
• Multiply effects of other drugs (especially alcohol)
• 1980s: azaspirones (BuSpar)
• Different receptors, same effectiveness, fewer problems
Slide 31
GAD: The Biological Perspective
 Biological treatments
• Relaxation training
• Theory: physical relaxation leads to psychological
relaxation
• Research indicates that relaxation training is more
effective than placebo or no treatment
• Best when used in combination with cognitive therapy
or biofeedback
Slide 32
GAD: The Biological Perspective
 Biological treatments
• Biofeedback
• Uses electrical signals from the body to train people to control
physiological processes
• EMG is the most widely used; provides feedback about muscle
tension
• Once hailed as the approach that would change clinical treatment
• Found to be most effective when used as an adjunct to other
methods for the treatment of certain medical problems
(headache, back pain, etc.)
Slide 33
Phobias
 From the Greek word for “fear”
• Formal names are also often from the Greek (see
Box 5-3)
 Persistent and unreasonable fears of particular
objects, activities, or situations
 Phobic people often avoid the object or
thoughts about it
Slide 34
Phobias
 We all have some fears at some points in our
lives; this is a normal and common
experience
• How do phobias differ from these “normal”
experiences?
• More intense fear
• Greater desire to avoid the feared object or situation
• Distress which interferes with functioning
Slide 35
Phobias
 Common in our society
• ~10% of adults affected in any given year
• ~14% develop a phobia at some point in lifetime
• Twice as common in women as men
 Most phobias are categorized as “specific”
• Two broader kinds:
• Social phobia
• Agoraphobia
Slide 36
Specific Phobias
 Persistent fears of specific objects or
situations
 When exposed to the object or situation,
sufferers experience immediate fear
 Most common: phobias of specific animals or
insects, heights, enclosed spaces,
thunderstorms, and blood
Slide 37
Specific Phobias
 ~9% of the U.S. population have symptoms in
any given year
• ~11% develop a specific phobia at some point in their
lives
 Many suffer from more than one phobia at a time
 Women outnumber men 2:1
 Prevalence differs across racial and ethnic
minority groups
Slide 38
Social Phobias
 Severe, persistent, and unreasonable fears of
social or performance situations in which
embarrassment may occur
• May be narrow – talking, performing, eating, or
writing in public
• May be broad – general fear of functioning
inadequately in front of others
• In both cases, people rate themselves as
performing less adequately than they actually did
Slide 39
Social Phobias
 Can greatly interfere with functioning
• Often kept a secret
 Affect ~8% of U.S. population in any given
year
 Women outnumber men 3:2
 Often begin in childhood and may persist for
many years
 Fewer than 20% of sufferers seek treatment
Slide 40
What Causes Phobias?
 All models offer explanations, but evidence
tends to support the behavioral explanations:
• Phobias develop through conditioning
• Once fears are acquired, they are continued
because feared objects are avoided
• Behaviorists propose a classical conditioning
model…
Slide 41
Classical Conditioning of Phobia
UCS
UCR
Entrapment
Fear
Running +
water
UCS
UCR
Entrapment
Fear
CS
CR
Running water
Fear
Slide 42
What Causes Phobias?
 Behavioral explanations
• Phobias develop through modeling
• Observation and imitation
• Phobias are maintained through avoidance
• Phobias may develop into GAD when a person
acquires a large number of phobias
• Process of stimulus generalization: responses to one
stimulus are also produced by similar stimuli
Slide 43
What Causes Phobias?
 Behavioral explanations have received some
empirical support:
• Classical conditioning study involving Little Albert
• Modeling studies
• Bandura, confederates, buzz, and shock
 Research conclusion is that phobias CAN be
acquired in these ways, but there is no evidence that
this is how the disorder is ordinarily acquired
Slide 44
What Causes Phobias?
 A behavioral-evolutionary explanation
• Some phobias are much more common than
others…
Slide 45
Slide 46
What Causes Phobias?
 A behavioral-evolutionary explanation
• Theorists argue that there is a species-specific
biological predisposition to develop certain fears
• Called “preparedness”: humans are more “prepared” to
develop phobias around certain objects or situations
• Model explains why some phobias (snakes, heights)
are more common than others (grass, meat)
• Unknown if these predispositions are due to evolutionary or
environmental factors
Slide 47
How Are Phobias Treated?
 All models offer treatment approaches
• Behavioral techniques (exposure treatments) are
most widely used, especially for specific phobias
• Shown to be highly effective
• Fare better in head-to-head comparisons than other
approaches
• Include desensitization, flooding, and modeling
Slide 48
Treatments for Specific Phobias
 Systematic desensitization
• Technique developed by Joseph Wolpe
• Create fear hierarchy
• Sufferers learn to relax while facing feared objects
• Since relaxation is incompatible with fear, the relaxation
response is thought to substitute for the fear response
• Several types:
• In vivo desensitization (live)
• Covert desensitization (imaginal)
Slide 49
Treatments for Specific Phobias
 Systematic desensitization
 Flooding
• Forced non-gradual exposure
 Modeling
• Therapist confronts the feared object while the fearful
person observes
 Clinical research supports these treatments
• The key to success is ACTUAL contact with the feared
object or situation
Slide 50
Treatments for Social Phobias
 Treatments only recently successful
• Two components must be addressed:
• Overwhelming social fear
• Address fears behaviorally with exposure
• Lack of social skills
• Social skills and assertiveness trainings have proved helpful
Slide 51
Treatments for Social Phobias
 Unlike specific phobias, social phobias respond well
to medication (particularly antianxiety drugs)
 Several types of psychotherapy have proved at least
as effective as medication
• People treated with psychotherapy are less likely to
relapse than people treated with drugs alone
• One psychological approach is exposure therapy, either in
an individual or group setting
• Cognitive therapies have also been widely used
Slide 52
Treatments for Social Phobias
 Another treatment option is social skills
training, a combination of several behavioral
techniques to help people improve their social
functioning
• Therapist provides feedback and reinforcement
 No single treatment approach is consistently
helpful or superior to the others
• Results from using a combination of approaches
seem to be most encouraging
Slide 53
Panic Disorder
 Panic, an extreme anxiety reaction, can result
when a real threat suddenly emerges
 The experience of “panic attacks,” however,
is different
• Panic attacks are periodic, short bouts of panic
that occur suddenly, reach a peak, and pass
• Sufferers often fear they will die, go crazy, or
lose control
• Attacks happen in the absence of a real threat
Slide 54
Slide 55
Panic Disorder
 Anyone can experience a panic attack, but
some people have panic attacks repeatedly,
unexpectedly, and without apparent reason
• Diagnosis: panic disorder
• Sufferers also experience dysfunctional changes in
thinking and behavior as a result of the attacks
• Example: sufferer worries persistently about having an
attack; plans behavior around possibility of future attack
Slide 56
Panic Disorder
 Often (but not always) accompanied by agoraphobia
• From the Greek “fear of the marketplace”
• Afraid to leave home and travel to locations from which
escape might be difficult or help unavailable
• Intensity may fluctuate
• There has only recently been a recognition of the link
between agoraphobia and panic attacks (or panic-like
symptoms)
Slide 57
Panic Disorder
 Two diagnoses: panic disorder with agoraphobia;
panic disorder without agoraphobia
• ~2.3% of U.S. population affected in a given year
• ~3.5% of U.S. population affected at some point in their
lives
 Likely to develop in late adolescence and early
adulthood
 Women are twice as likely as men to be affected
Slide 58
Panic Disorder: The Biological
Perspective
 In the 1960s, it was recognized that people with
panic disorder were not helped by
benzodiazepines, but were helped by
antidepressants
• Researchers worked backward from their
understanding of antidepressant drugs
Slide 59
Panic Disorder: The Biological
Perspective
 What biological factors contribute to panic disorder?
• NT at work is norepinephrine
• Irregular in people with panic attacks
• Research suggests that panic reactions are related to changes
in norepinephrine activity in the locus ceruleus
• While norepinephrine is clearly linked to panic disorder,
what goes wrong isn’t exactly understood
• May be excessive activity, deficient activity, or some other defect
• Other NTs are likely involved
Slide 60
Panic Disorder: The Biological
Perspective
 It is also unclear why some people have such
biological abnormalities
• Inherited biological predisposition is one possible
reason
• If so, prevalence should be (and is) greater among
close relatives
• Among monozygotic (MZ or identical) twins = 24%
• Among dizygotic (DZ or fraternal) twins = 11%
• Issue is still open to debate
Slide 61
Panic Disorder: The Biological
Perspective
 Drug therapies
• Antidepressants are effective at preventing or reducing
panic attacks
• Function at norepinephrine receptors in the locus ceruleus
• Bring at least some improvement to 80% of patients with panic
disorder
• ~40–60% recover markedly or fully
• Require maintenance of drug therapy; otherwise relapse rates are
high
• Some benzodiazepines (especially Xanax (alprazolam))
have also proved helpful
Slide 62
Panic Disorder: The Biological
Perspective
 Drug therapies
• Both antidepressants and benzodiazepines are also helpful
in treating panic disorder with agoraphobia
• Break the cycle of attack, anticipation, and fear
 It is important to note that when drug therapy is
stopped, symptoms return
• Combination treatment (medications + behavioral
exposure therapy) may be more effective than either
treatment alone
Slide 63
Panic Disorder: The Cognitive
Perspective
 Cognitive theorists and practitioners
recognize that biological factors are only part
of the cause of panic attacks
• In their view, full panic reactions are experienced
only by people who misinterpret bodily events
• Cognitive treatment is aimed at changing such
misinterpretations
Slide 64
Panic Disorder: The Cognitive
Perspective
 Misinterpreting bodily sensations
• Panic-prone people may be overly sensitive to certain
bodily sensations and may misinterpret them as signs of a
medical catastrophe; this leads to panic
• Why might some people be prone to such
misinterpretations?
• Poor coping skills
• Lack of social support
• Unpredictable childhoods
• Overly protective parents
Slide 65
Panic Disorder: The Cognitive
Perspective
 Misinterpreting bodily sensations
• Panic-prone people have a high degree of “anxiety
sensitivity”
• They focus on bodily sensations much of the time, are unable to
assess the sensations logically, and interpret them as potentially
harmful
• Examples include: overbreathing or hyperventilation, excitement,
fullness in the abdomen, acute anger, and heart “palpitations”
Slide 66
Panic Disorder: The Cognitive
Perspective
 Cognitive therapy
• Attempts to correct people’s misinterpretations of their
bodily sensations
• Step 1: Educate clients
• About panic in general
• About the causes of bodily sensations
• About their tendency to misinterpret the sensations
• Step 2: Teach clients to apply more accurate interpretations
(especially when stressed)
• Step 3: Teach clients skills for coping with anxiety
• Examples: relaxation, breathing
Slide 67
Panic Disorder: The Cognitive
Perspective
 Cognitive therapy
• May also use “biological challenge” procedures
to induce panic sensations
• Induce physical sensations which cause feelings of
panic:
• Jump up and down
• Run up a flight of steps
• Practice coping strategies and making more accurate
interpretations
Slide 68
The Cognitive Perspective
 Cognitive therapy is often helpful in panic disorder
• 85% panic-free for two years vs. 13% of control subjects
• Only sometimes helpful for panic disorder with
agoraphobia
• At least as helpful as antidepressants
 Combination therapy may be most effective
• Still under investigation
Slide 69
Obsessive-Compulsive Disorder
 Comprised of two components:
• Obsessions
• Persistent thoughts, ideas, impulses, or images that
seem to invade a person’s consciousness
• Compulsions
• Repeated and rigid behaviors or mental acts that
people feel they must perform in order to prevent or
reduce anxiety
Slide 70
Obsessive-Compulsive Disorder
 Diagnosis may be called for when symptoms:
• Feel excessive or unreasonable
• Cause great distress
• Consume considerable time
• Or interfere with daily functions
Slide 71
Obsessive-Compulsive Disorder
 Classified as an anxiety disorder because
obsessions cause anxiety, while compulsions
are aimed at preventing or reducing anxiety
• Anxiety rises if obsessions or compulsions are
avoided
 ~2% of U.S. population has OCD in a given
year
 Ratio of women to men is 1:1
Slide 72
What Are the Features of Obsessions
and Compulsions?
 Obsessions
• Thoughts that feel intrusive and foreign
• Attempts to ignore or avoid them triggers anxiety
• Take various forms:
• Have common themes:
• Wishes
• Dirt/contamination
• Impulses
• Violence and aggression
• Images
• Orderliness
• Ideas
• Religion
• Doubts
• Sexuality
Slide 73
What Are the Features of Obsessions
and Compulsions?
 Compulsions
• “Voluntary” behaviors or mental acts
• Feel mandatory/unstoppable
• Person may recognize that behaviors are irrational
• Believe, though, that catastrophe will occur if they don’t
perform the compulsive acts
• Performing behaviors reduces anxiety
• ONLY FOR A SHORT TIME!
• Behaviors often develop into rituals
Slide 74
What Are the Features of Obsessions
and Compulsions?
 Compulsions
• Common forms/themes:
• Cleaning
• Checking
• Order or balance
• Touching, verbal, and/or counting
Slide 75
What Are the Features of Obsessions
and Compulsions?
 Are obsessions and compulsions related?
• Most (not all) people with OCD experience both
• Compulsive acts often occur in response to
obsessive thoughts
• Compulsions seem to represent a yielding to
obsessions
• Compulsions also sometimes serve to help control
obsessions
Slide 76
What Are the Features of Obsessions
and Compulsions?
 Are obsessions and compulsions related?
• Many with OCD are concerned that they will act
on their obsessions
• Most of these concerns are unfounded
• Compulsions usually do not lead to violence or
“immoral acts”
Slide 77
Obsessive-Compulsive Disorder
 OCD was once among the least understood of
the psychological disorders
 In recent years, however, researchers have
begun to learn more about it
 The most influential explanations are from the
psychodynamic, behavioral, cognitive, and
biological models…
Slide 78
OCD: The Psychodynamic Perspective
 Anxiety disorders develop when children come to
fear their id impulses and use ego defense
mechanisms to lessen their anxiety
 OCD differs from anxiety disorders in that the
“battle” is not unconscious; it is played out in
explicit thoughts and action
• Id impulses = obsessive thoughts
• Ego defenses = counter-thoughts or compulsive actions
 At its core, OCD is related to aggressive impulses and
the competing need to control them
Slide 79
OCD: The Psychodynamic Perspective
 The battle between the id and the ego
• Three ego defenses mechanisms are common:
• Isolation: disown disturbing thoughts
• Undoing: perform acts to “cancel out” thoughts
• Reaction formation: take on lifestyle in contrast to unacceptable
impulses
• Freud believed that OCD was related to the anal stage of
development
• Period of intense conflict between id and ego
• Not all psychodynamic theorists agree
Slide 80
OCD: The Psychodynamic Perspective
 Psychodynamic therapies
• Goals are to uncover and overcome underlying
conflicts and defenses
• Main techniques are free association and
interpretation
• Research evidence is poor
• In fact, psychodynamic therapy may be detrimental for
OCD by playing into the tendency to “think too much”
Slide 81
OCD: The Behavioral Perspective
 Behaviorists concentrate on explaining and
treating compulsions
 Although the behavioral explanation of OCD
has received little support, behavioral
treatments for compulsive behaviors have
been very successful
Slide 82
OCD: The Behavioral Perspective
 Learning by chance
• People happen upon compulsions randomly:
• In a fearful situation, they happen to perform a particular act
(washing hands)
• When the threat lifts, they associate the improvement with the
random act
• After repeated associations, they believe the compulsion
is changing the situation
• Bringing luck, warding away evil, etc.
• The act becomes a key method to avoiding or reducing
anxiety
Slide 83
OCD: The Behavioral Perspective
 Key investigator: Stanley Rachman
• Compulsions are rewarded by an eventual
decrease in anxiety
• Studies provide no evidence of the learning of
compulsions
Slide 84
OCD: The Behavioral Perspective
 Behavioral therapy
• Exposure and response prevention (ERP)
• Clients are repeatedly exposed to anxiety-provoking stimuli and
prevented from responding with compulsions
• Therapists often model the behavior while the client watches
• Homework is an important component
• Treatment is offered in individual and group settings
• Treatment provides significant, long-lasting improvements for
most patients
Slide 85
OCD: The Cognitive Perspective
 Cognitive theory and treatment for OCD is
very promising
• Includes a number of behavioral principles, and
thus has been called “cognitive-behavioral”
Slide 86
OCD: The Cognitive Perspective
 Overreacting to unwanted thoughts
• People with OCD blame themselves for normal (although
repetitive and intrusive) thoughts and expect that terrible
things will happen as a result
• To avoid such negative outcomes, they attempt to neutralize their
thoughts with actions (or other thoughts)
• Neutralizing thoughts/actions may include:
• Seeking reassurance
• Thinking “good” thoughts
• Washing
• Checking
Slide 87
OCD: The Cognitive Perspective
 When a neutralizing action reduces anxiety, it
is reinforced
• Client becomes more convinced that the thoughts
are dangerous
• As fear of thoughts increases, the number of
thoughts increases
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OCD: The Cognitive Perspective
 If everyone has intrusive thoughts, why do only
some people develop OCD?
• People with OCD:
• Are more depressed than others
• Have higher standards of morality and conduct
• Believe thoughts = actions and are capable of bringing harm
• Believe that they can and should have perfect control over their
thoughts and behaviors
 Good research support for this model
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OCD: The Cognitive Perspective
 Cognitive therapies
• Used in combination with behavioral techniques
• May include:
• Habituation training
• Covert-response prevention
Slide 90
OCD: The Biological Perspective
 Significant attempts have been made to
identify hidden biological factors that might
contribute to the development of OCD
• Research has led to promising theories and
treatments
Slide 91
OCD: The Biological Perspective
 Two lines of research:
• Role of NT serotonin
• Evidence that serotonin-based antidepressants reduce OCD
symptoms
• Brain abnormalities
• OCD linked to orbital region of frontal cortex and caudate nuclei
• Compose brain circuit that converts sensory information into
thoughts and actions
• Either area may be too active, letting through troublesome
thoughts and actions
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OCD: The Biological Perspective
 Some research support and evidence that
these two lines may be connected
• Serotonin plays a very active role in the operation
of the orbital region and the caudate nuclei
• Low serotonin activity might interfere with the proper
functioning of these brain parts
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OCD: The Biological Perspective
 Biological therapies
• Serotonin-based antidepressants
• Anafranil, Prozac, Luvox
• Bring improvement to 50–80% of those with OCD
• Relapse occurs if medication is stopped
• Research suggests that combination therapy
(medication + cognitive behavioral therapy
approaches) may be most effective
• May have same effect on the brain
Slide 94