Anxiety Disorders

1
Chapter 5
Slides Handouts by Karen Clay Rhines,
Ph.D. Seton Hall University

• Anxiety Disorders

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Anxiety

• What distinguishes fear from anxiety?
• Fear is a state of immediate alarm in response to
  a serious, known threat to ones 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.

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Anxiety

• Is the fear/anxiety response useful/adaptive?
• Yes, when the fight or flight response is
  protective
• However, 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

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Anxiety Disorders

• Most common mental disorders in the U.S.
• In any given year, 18 of the adult population in
  the U.S. experiences one of the six DSM-IV-TR
  anxiety disorders
• Close to 29 develop one of the disorders at some
  point in their lives
• Only 20 of these individuals seek treatment
• Most individuals with one anxiety disorder suffer
  from a second disorder, as well
• Anxiety disorders cost 42 billion each year in
  health care, lost wages, and lost productivity

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Anxiety Disorders

• Six disorders
• Generalized anxiety disorder (GAD)
• Phobias
• Panic disorder
• Obsessive-compulsive disorder (OCD)
• Acute stress disorder
• Posttraumatic stress disorder (PTSD)

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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

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Generalized Anxiety Disorder (GAD)

• The disorder is common in Western society
• Affects 3 of the population in any given year
  and 6 at sometime during their lives
• Usually first appears in childhood or adolescence
• Women are diagnosed more often than men by 21
  ratio
• Various theories have been offered to explain the
  development of the disorder

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GAD The Sociocultural Perspective

• According to this theory, GAD is most likely to
  develop in people faced with social conditions
  that truly are 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, there are
  higher rates of GAD in lower SES groups

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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, 6 of African Americans and
  3.1 of Caucasians suffer from GAD
• African American women have highest rates (6.6)

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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 dont work
  or when anxiety is too highGAD develops

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GAD The Psychodynamic Perspective

• Todays psychodynamic theorists often disagree
  with specific aspects of Freuds explanation
• Researchers have found some support for the
  psychodynamic perspective
• People with GAD are particularly likely to use
  defense mechanisms (especially repression)
• Children who were severely punished for
  expressing id impulses have higher levels of
  anxiety later in life
• Are these results proof of the models
  validity?

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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
• Also, some data actually contradict the model
• Many (if not most) GAD clients report normal
  childhood upbringings

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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 therapists help patients
  identify and settle early relationship conflicts

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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 Rogerss
  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

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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 Rogerss
  explanation of causal factors

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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

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GAD The Cognitive Perspective

• Theory GAD is caused by maladaptive assumptions
• Albert Ellis identified basic irrational
  assumptions
• It is necessary for humans to be loved by
  everyone
• It is catastrophic when things are not as one
  wants them to be
• 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

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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
• Research supports the presence of these types of
  assumptions in GAD, particularly about
  dangerousness

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GAD The Cognitive Perspective

• Second-Generation Cognitive Explanations
• In recent years, two promising explanations have
  emerged
• Metacognitive theory
• Worry about worrying (metaworrying)
• Avoidance theory
• worrying serves a positive function by reducing
  unusually high levels of bodily arousal
• Both theories have received considerable research
  support

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GAD The Cognitive Perspective

• Two kinds of cognitive therapy
• Changing maladaptive assumptions
• Based on the work of Ellis and Beck
• Helping clients understand the special role that
  worrying plays, and changing their views about it

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GAD The Cognitive Perspective

• Cognitive therapies
• Focusing on worrying
• Therapists begin with psychoeducation about
  worrying and GAD
• Assign self-monitoring of somatic arousal and
  cognitive responses
• As therapy progresses, clients become
  increasingly skilled at identifying their
  worrying and its counterproductivity

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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)
  than general population (6)
• The closer the relative, the greater the
  likelihood
• Issue of shared environment

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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

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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 buspirone (BuSpar)
• Different receptors, same effectiveness, fewer
  problems

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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

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GAD The Biological Perspective

• Biological treatments
• Biofeedback
• Therapist uses electrical signals from the body
  to train people to control physiological
  processes
• Electromyograph (EMG) is the most widely used
  provides feedback about muscle tension
• Found to be most effective when used as an
  adjunct to other methods for the treatment of
  certain medical problems (headache, back pain,
  etc.)

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Phobias

• From the Greek word for fear
• Formal names are also often from the Greek (see
  Box 5-2)
• Persistent and unreasonable fears of particular
  objects, activities, or situations
• Phobic people often avoid the object or thoughts
  about it

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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 that interferes with functioning

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Specific Phobias

• Persistent fear 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

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Specific Phobias

• 9 of the U.S. population have symptoms in any
  given year
• 12 develop a specific phobia at some point in
  their lives
• Many suffer from more than one phobia at a time
• Women outnumber men 21
• Prevalence differs across racial and ethnic
  minority groups
• Vast majority do NOT seek treatment

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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

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Social Phobias

• Can greatly interfere with functioning
• Often kept a secret
• Affect 7 of U.S. population in any given year
• Women outnumber men 32
• Often begin in childhood and may persist for many
  years

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What Causes Phobias?

• Each model offers 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

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What Causes Phobias?

• Other behavioral explanations
• Phobias may 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 elicited by similar stimuli

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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

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What Causes Phobias?

• A behavioral-evolutionary explanation
• Some phobias are much more common than others

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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

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How Are Phobias Treated?

• Surveys reveal that 19 of those with specific
  phobia and 25 of those with social phobia
  currently are in treatment
• Each model offers 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

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Treatments for Specific Phobias

• Systematic desensitization
• Technique developed by Joseph Wolpe
• Teach relaxation skills
• 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)

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Treatments for Specific Phobias

• Other behavioral treatments
• Flooding
• Forced nongradual exposure
• Modeling
• Therapist confronts the feared object while the
  fearful person observes
• Clinical research supports each of these
  treatments
• The key to success is ACTUAL contact with the
  feared object or situation

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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

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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

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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

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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)

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Panic Disorder

• Two diagnoses panic disorder with agoraphobia
  panic disorder without agoraphobia
• 3 of U.S. population affected in a given year
• 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
• Approximately 35 of those with panic disorder
  are in treatment

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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

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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
• Although norepinephrine is clearly linked to
  panic disorder, what goes wrong isnt exactly
  understood
• May be excessive activity, deficient activity, or
  some other defect
• Other NTs and brain circuits seem to be involved

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Panic Disorder The Biological Perspective

• It is also unclear why some people have such
  abnormalities in norepinephrine activity
• 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

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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 correcting such
  misinterpretations

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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

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Panic Disorder The Cognitive Perspective

• Cognitive therapy
• Attempts to correct peoples 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

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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

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Obsessive-Compulsive Disorder

• Made up of two components
• Obsessions
• Persistent thoughts, ideas, impulses, or images
  that seem to invade a persons consciousness
• Compulsions
• Repeated and rigid behaviors or mental acts that
  people feel they must perform to prevent or
  reduce anxiety

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Obsessive-Compulsive Disorder

• Diagnosis may be called for when symptoms
• Feel excessive or unreasonable
• Cause great distress
• Consume considerable time
• Interfere with daily functions

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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
  between 2 and 3 over a lifetime
• Ratio of women to men is 11
• It is estimated that more than 40 of those with
  OCD seek treatment

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What Are the Features of Obsessions and
Compulsions?

• Obsessions
• Thoughts that feel intrusive and foreign
• Attempts to ignore or avoid them trigger anxiety

• Take various forms
• Wishes
• Impulses
• Images
• Ideas
• Doubts

• Have common themes
• Dirt/contamination
• Violence and aggression
• Orderliness
• Religion
• Sexuality

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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 dont perform the compulsive acts
• Performing behaviors reduces anxiety
• ONLY FOR A SHORT TIME!
• Behaviors often develop into rituals

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What Are the Features of Obsessions and
Compulsions?

• Compulsions
• Common forms/themes
• Cleaning
• Checking
• Order or balance
• Touching, verbal, and/or counting

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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

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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

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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

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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

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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

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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
• Some therapists now prefer to treat these
  patients with short-term psychodynamic therapies

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OCD The Behavioral Perspective

• Behaviorists concentrate on explaining and
  treating compulsions rather than obsessions
• Although the behavioral explanation of OCD has
  received little support, behavioral treatments
  for compulsive behaviors have been very successful

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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

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OCD The Behavioral Perspective

• Key investigator Stanley Rachman
• Compulsions do appear to be rewarded by an
  eventual decrease in anxiety
• Studies provide no evidence of the learning of
  compulsions

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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
• However, as many as 25 fail to improve at all
  and the approach is of limited help to those with
  obsessions but no compulsions

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OCD The Cognitive Perspective

• Cognitive theory begins by pointing out that
  everyone has repetitive, unwanted, and intrusive
  thoughts
• People with OCD blame themselves for normal
  (although repetitive and intrusive) thoughts and
  expect that terrible things will happen as a
  result

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OCD The Cognitive Perspective

• Overreacting to unwanted thoughts
• 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 tend
• To be more depressed than others
• To have higher standards of morality and conduct
• To believe thoughts are equal to actions and are
  capable of bringing harm
• To believe that they can and should have perfect
  control over their thoughts and behaviors

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OCD The Cognitive Perspective

• Cognitive therapies
• Focus on the cognitive processes that help to
  produce and maintain obsessive thoughts and
  compulsive acts
• May include
• Psychoeducation
• Habituation training

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OCD The Cognitive Perspective

• Cognitive-Behavioral Therapy (CBT)
• Research suggests that a combination of the
  cognitive and behavioral models often is more
  effective than either intervention alone
• These treatments typically include
  psychoeducation and exposure and response
  prevention exercises

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OCD The Biological Perspective

• Family pedigree studies provided the first clues
  that OCD may be linked in part to biological
  factors
• Studies of twins found a 53 concordance rate in
  identical twins versus 23 in fraternal twins
• Currently, more direct genetic studies are being
  conducted to try to pinpoint the cause of the
  genetic predisposition

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OCD The Biological Perspective

• Two additional 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
• 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 provides 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
• clomipramine (Anafranil), fluoxetine (Prozac),
  fluvoxamine
• Bring improvement to 5080 of those with OCD
• Relapse occurs if medication is stopped
• Research suggests that combination therapy
  (medication cognitive behavioral therapy
  approaches) may be most effective