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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

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chapter 5

Chapter 5

Anxiety Disorders

Slides & Handouts by Karen Clay Rhines, Ph.D.

Seton Hall University

anxiety
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.
anxiety3
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
anxiety disorders
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
anxiety disorders5
Anxiety Disorders
  • Six disorders:
    • Generalized anxiety disorder (GAD)
    • Phobias
    • Panic disorder
    • Obsessive-compulsive disorder (OCD)
    • Acute stress disorder
    • Post-traumatic stress disorder (PTSD)
generalized anxiety disorder gad
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
generalized anxiety disorder gad7
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…
gad the sociocultural perspective
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
gad the sociocultural perspective9
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%)
gad the sociocultural perspective10
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…
gad the psychodynamic perspective
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!
gad the psychodynamic perspective12
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?
gad the psychodynamic perspective13
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
gad the psychodynamic perspective14
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
gad the psychodynamic perspective15
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
gad the humanistic perspective
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
gad the humanistic perspective17
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
gad the cognitive perspective
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…
gad the cognitive perspective19
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
gad the cognitive perspective20
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
gad the cognitive perspective21
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
gad the cognitive perspective22
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
gad the cognitive perspective23
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
gad the cognitive perspective24
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
gad the cognitive perspective25
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
gad the cognitive perspective26
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
gad the biological perspective
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
gad the biological perspective28
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 gamma-aminobutyric acid (GABA, a common NT in the brain)
        • GABA is an inhibitory messenger; when received, it causes a neuron to STOP firing
gad the biological perspective29
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
gad the biological perspective30
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?
gad the biological perspective31
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
gad the biological perspective32
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
gad the biological perspective33
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.)
phobias
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
phobias35
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
phobias36
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
specific phobias
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
specific phobias38
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
social phobias
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
social phobias40
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
what causes phobias
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…
classical conditioning of phobia
Classical Conditioning of Phobia

UCS

Entrapment

UCR

Fear

UCS

Entrapment

UCR

Fear

Running water

+

CR

Fear

CS

Running water

what causes phobias43
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
what causes phobias44
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
what causes phobias45
What Causes Phobias?
  • A behavioral-evolutionary explanation
    • Some phobias are much more common than others…
what causes phobias47
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
how are phobias treated
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
treatments for specific phobias
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)
treatments for specific phobias50
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
treatments for social phobias
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
treatments for social phobias52
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
treatments for social phobias53
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
panic disorder
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
panic disorder56
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
panic disorder57
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)
panic disorder58
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
panic disorder the biological perspective
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
panic disorder the biological perspective60
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
panic disorder the biological perspective61
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
panic disorder the biological perspective62
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
panic disorder the biological perspective63
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
panic disorder the cognitive perspective
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
panic disorder the cognitive perspective65
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
panic disorder the cognitive perspective66
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”
panic disorder the cognitive perspective67
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
panic disorder the cognitive perspective68
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
the cognitive perspective
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
obsessive compulsive disorder
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
obsessive compulsive disorder71
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
obsessive compulsive disorder72
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
what are the features of obsessions and compulsions
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:
    • Wishes
    • Impulses
    • Images
    • Ideas
    • Doubts
  • Have common themes:
    • Dirt/contamination
    • Violence and aggression
    • Orderliness
    • Religion
    • Sexuality
what are the features of obsessions and compulsions74
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
what are the features of obsessions and compulsions75
What Are the Features of Obsessions and Compulsions?
  • Compulsions
    • Common forms/themes:
      • Cleaning
      • Checking
      • Order or balance
      • Touching, verbal, and/or counting
what are the features of obsessions and compulsions76
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
what are the features of obsessions and compulsions77
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”
obsessive compulsive disorder78
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…
ocd the psychodynamic perspective
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
ocd the psychodynamic perspective80
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
ocd the psychodynamic perspective81
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”
ocd the behavioral perspective
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
ocd the behavioral perspective83
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
ocd the behavioral perspective84
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
ocd the behavioral perspective85
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
ocd the cognitive perspective
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”
ocd the cognitive perspective87
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
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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
ocd the biological perspective
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
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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
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