Abnormal Psychology, 18th Ed (Jim M. Hooley, Matthew K. Nock etc.) (z-lib.org)

214 Chapter 6
MEDICATIONS Many clients with generalized anxiety
disorder consult family physicians, seeking relief from
their “nerves” or anxieties or their various functional (psy-
chogenic) physical problems. Most often in such cases,
medications from the benzodiazepine (anxiolytic) category
such as Xanax or Klonopin are used—and misused—for
tension relief, reduction of other somatic symptoms, and
relaxation. Their eects on worry and other psychological
symptoms are not as great. Moreover, they can create phys-
iological and psychological dependence and withdrawal
and are therefore dicult to taper. A newer medication
called buspirone (from a dierent medication category) is
also eective, and it is neither sedating nor does it lead to
physiological dependence. It also has greater eects on
psychic anxiety than do the benzodiazepines. However, it
may take 2 to 4 weeks to show results (Roy-Byrne &
Cowley, 2002, 2007). Several categories of antidepressant
medications like those used in the treatment of panic disor-
der are also useful in the treatment of GAD, and they also
seem to have a greater eect on the psychological symp-
toms of GAD than do the benzodiazepines (Goodman,
2004; Roy-Byrne & Cowley, 2002, 2007). However, they
take several weeks before their eects are apparent.
Obsessive-Compulsive
and Related Disorders
6.7 Describe the clinical features of obsessive-
compulsive disorder and how it is treated.
Obsessive-compulsive and related disorders used to be classi-
fied in the DSM as anxiety disorders; however, as of DSM-5
they have been classified separately as their own type of disor-
der (see the Thinking Critically about DSM-5 box). This new cat-
egory includes not only OCD but also body dysmorphic
disorder, hoarding disorder, excoriation (skin-picking) disor-
der, and trichotillomania (compulsive hair pulling).
Obsessive-Compulsive Disorder
Obsessive-compulsive disorder is defined by the occur-
rence of both obsessive thoughts and compulsive
behaviors performed in an attempt to neutralize such
thoughts (see the DSM-5 box for diagnostic criteria).
NEUROBIOLOGICAL DIFFERENCES BETWEEN ANXIETY
AND PANIC As we noted at the beginning of this chapter,
contemporary theorists are drawing several fundamental
distinctions between fear, panic, and anxiety, including their
neurobiological bases. Fear and panic involve activation of
the fight-or-flight response, and the brain areas and neu-
rotransmitters that seem most strongly implicated in these
emotional responses are the amygdala (and locus coeruleus)
and the neurotransmitters norepinephrine and serotonin.
Generalized anxiety (or anxious apprehension) is a more dif-
fuse emotional state than acute fear or phobia that involves
arousal and a preparation for possible impending threat;
and the brain area, neurotransmitters, and hormones that
seem most strongly implicated are the limbic system (espe-
cially the bed nucleus of the stria terminalis, an extension of
the amygdala), GABA, and CRH (Davis, 2006; Lang et al.,
2000). Although serotonin may play a role in both anxiety
and panic, it probably does so in somewhat dierent ways.
Recently, people with GAD have been found to have a
smaller left hippocampal region similar to what is seen with
major depression (Hettema et al., 2012); this may represent a
common risk factor for the two disorders.
Treatments
As noted earlier, most treatment for GAD involves cogni-
tive-behavioral or medicinal approaches.
COGNITIVE-BEHAVIORAL TREATMENT CBT for gener-
alized anxiety disorder has become increasingly eective as
clinical researchers have refined the techniques used. It usu-
ally involves a combination of behavioral techniques, such as
training in applied muscle relaxation, and cognitive restruc-
turing techniques aimed at reducing distorted cognitions
and information-processing biases associated with GAD as
well as reducing catastrophizing about minor events (Barlow
et al., 2007; Borkovec, 2006). GAD initially appeared to be
among the most dicult of the anxiety disorders to treat, and
to some extent this is still true. However, advances have been
made, and a quantitative review of many controlled studies
showed that CBT approaches resulted in large changes on
most symptoms measured (Mitte, 2005). The magnitude of
the changes seen with cognitive-behavioral treatment was at
least as large as those seen with benzodiazepines, and it led
to fewer dropouts (i.e., it was better tolerated). Finally, CBT
has also been found to be useful in helping people who have
used benzodiazepines for over a year to successfully taper
their medications (Gosselin et al., 2006).
CBT for Rodney’s GAD
The case of Rodney, the graduate student with GAD discussed ear-
lier, serves as an example of the success of cognitive-behavioral
therapy with this condition. Before receiving CBT, Rodney had seen
someone at a student counseling center for several months, but he
hadn’t found the “talk therapy” very useful. He had heard that CBT
might be useful and had sought such treatment. He was in treat-
ment for about 6 months, during which time he found training in
deep muscle relaxation helpful in reducing his overall level of tension.
Cognitive restructuring helped reduce his worry levels about all
spheres of his life. He still had problems with procrastinating when
he had deadlines, but this too was improving. He also began social-
izing more frequently and had tentatively begun dating when treat-
ment ended for financial reasons. He could now see that if a woman
didn’t want to go out with him again, this did not mean that he was
boring but simply that they might not be a good match.
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Panic, Anxiety, Obsessions, and Their Disorders 215
DSM-5 Thinking Critically about DSM-5
Why Is OCD No Longer Considered to Be an Anxiety Disorder?
In DSM-5, obsessive-compulsive disorder was removed from the
anxiety disorders category and placed into a new category called
“obsessive-compulsive and related disorders.” (As you already
know from Chapter 5, PTSD was also removed and put into a
new category called “trauma and stressor-related disorders.”)
One reason for moving OCD into the new category was that
anxiety is not generally used as an indicator of OCD severity.
Indeed, for people with certain forms of OCD such as symmetry-
related obsessions and compulsions, anxiety is not even a prom-
inent symptom. It was also noted that anxiety occurs in a wide
range of disorders, so the presence of some anxiety is not a valid
reason to regard OCD as an anxiety disorder. Indeed D. J. Stein
et al. (2010) wrote that “the highly stereotyped, driven, repetitive,
and nonfunctional quality of compulsive behaviors dierentiate
OCD from normal acts and from the types of avoidance that
occur in other anxiety disorders” (p. 497).
Yet another reason is that the neurobiological underpinnings
of OCD appear to be rather dierent from those of other anxiety
disorders, focusing on frontal-striatal neural circuitry including the
orbitofrontal cortex, anterior cingulate cortex, and striatum (espe-
cially the caudate nucleus). Studies examining the “OCD-related
disorders” such as body dysmorphic disorder (obsessing about
perceived or imagined flaws in physical appearance) and trichotil-
lomania (chronic hair pulling) also suggest shared involvement of
frontal-striatal neural circuitry. Finally, other anxiety disorders
respond to a wider range of medication treatments than does
OCD, which seems to respond selectively to SSRIs.
How compelling do these reasons sound to you? What kinds
of research findings might further support the grouping of OCD
with related disorders such as hoarding or trichotillomania? On the
contrary, what research findings might incline you to think that it
was wrong to remove OCD from the anxiety disorders category?
DSM-5 Criteria for. . .
Obsessive-Compulsive Disorder
A. Presence of obsessions, compulsions, or both: Obsessions
are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that
are experienced, at some time during the disturbance, as
intrusive and unwanted, and that in most individuals
cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such
thoughts, urges, or images, or to neutralize them with
some other thought or action (i.e., by performing a com-
pulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering,
checking) or mental acts (e.g., praying, counting, repeat-
ing words silently) that the individual feels driven to per-
form in response to an obsession or according to rules
that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or
reducing anxiety or distress, or preventing some dreaded
event or situation; however, these behaviors or mental
acts are not connected in a realistic way with what they
are designed to neutralize or prevent, or are clearly
excessive.
Note: Young children may not be able to articulate the aims of
these behaviors or mental acts.
B. The obsessions or compulsions are time-consuming (e.g.,
take more than 1 hour per day) or cause clinically significant
distress or impairment in social, occupational, or other impor-
tant areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to
the physiological eects of a substance (e.g., a drug of abuse,
a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of
another mental disorder (e.g., excessive worries, as in general-
ized anxiety disorder; preoccupation with appearance, as in
body dysmorphic disorder; diculty discarding or parting with
possessions, as in hoarding disorder; hair pulling, as in trichotil-
lomania [hair-pulling disorder]; skin picking, as in excoriation
[skin-picking] disorder; stereotypies, as in stereotypic movement
disorder; ritualized eating behavior, as in eating disorders; preoc-
cupation with substances or gambling, as in substance-related
and addictive disorders; preoccupation with having an illness, as
in illness anxiety disorder; sexual urges or fantasies, as in para-
philic disorders; impulses, as in disruptive, impulse-control, and
conduct disorders; guilty ruminations, as in major depressive
disorder; thought insertion or delusional preoccupations, as in
schizophrenia spectrum and other psychotic disorders; or repet-
itive patterns of behavior, as in autism spectrum disorder).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.
Obsessions are persistent and recurrent intrusive
thoughts, images, or impulses that are experienced as dis-
turbing, inappropriate, and uncontrollable. People who
have such obsessions actively try to resist or suppress
them or to neutralize them with some other thought or
action. Compulsions involve overt repetitive behaviors
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216 Chapter 6
Many obsessive thoughts involve contamination fears,
fears of harming oneself or others, and pathological doubt.
Other fairly common themes are concerns about or need
for symmetry (e.g., having magazines on a table arranged
in a way that is “exactly right”), sexual obsessions, and
obsessions concerning religion or aggression. These themes
are quite consistent cross-culturally and across the life span
(Steketee & Barlow, 2002). Obsessive thoughts involving
themes of violence or aggression might include a wife
being obsessed with the idea that she might poison her
husband or child, or a daughter constantly imagining
pushing her mother down a flight of stairs. Even though
such obsessive thoughts are very rarely acted on, they
remain a source of often excruciating torment to a person
plagued with them. The following case of Mark is fairly
typical of severe OCD.
Obsessions about Confessing and Compulsive
Checking
Mark was a 28-year-old single male who, at the time he entered
treatment, suered from severe obsessive thoughts and images
about causing harm to others such as running over pedestrians
while he was driving. He also had severe obsessions that he
would commit a crime such as robbing a store of a large amount
of money or poisoning family members or friends. These obses-
sions were accompanied by lengthy and excessive checking ritu-
als. For example, one day when he drove, he began obsessing
that he had caused an accident and hit a pedestrian at an inter-
section, and he felt compelled to spend several hours driving and
walking around all parts of that intersection to find evidence of the
accident.
At the time Mark went to an anxiety disorder clinic, he was no
longer able to live by himself after having lived alone for several
years since college. He was a very bright young man with consid-
erable artistic talent. He had finished college at a prestigious
school for the arts and had launched a successful career as a
young artist when the obsessions began in his early 20s. At first,
they were focused on the possibility that he would be implicated
in some crime that he had not committed; later, they evolved to
the point where he was afraid that he might actually commit a
crime and confess to it. The checking rituals and avoidance of all
places where such confessions might occur eventually led to his
having to give up his career and his own apartment and move
back in with his family.
At the time he presented for treatment, Mark’s obsessions
about harming others and confessing to crimes (whether or not he
had committed them) were so severe that he had virtually confined
himself to his room at his parents’ house. Indeed, he could leave his
room only if he had a tape recorder with him so that he would have
a record of any crimes he confessed to out loud because he did not
trust his own memory. The clinic was several hours’ drive from his
home; his mother usually had to drive because of his obsessions
about causing accidents with pedestrians or moving vehicles and
because the associated checking rituals could punctuate any trip
with several very long stops. He also could not speak at all on the
phone for fear of confessing some crime that he had (or had not)
that are performed as lengthy rituals (such as hand
washing, checking, putting things in order over and over
again). Compulsions may also involve more covert mental
rituals (such as counting, praying, or saying certain words
silently over and over again). A person with OCD usually
feels driven to perform this compulsive, ritualistic behav-
ior in response to an obsession, and there are often very
rigid rules regarding exactly how the compulsive behav-
ior should be performed. The compulsive behaviors are
performed with the goal of preventing or reducing
distress or preventing some dreaded event or situation.
OCD is often one of the most disabling mental disorders
in that it leads to a lower quality of life and a great deal of
functional impairment (Stein et al., 2009).
In addition, the person must recognize that the obses-
sion is the product of his or her own mind rather than
being imposed from without (as might occur in schizo-
phrenia). However, there is a continuum of “insight”
among persons with OCD about exactly how senseless
and excessive their obsessions and compulsions are (Rus-
cio et al., 2010). In a minority of cases, this insight is absent
most of the time. Most of us have experienced minor
obsessive thoughts, such as whether we remembered to
lock the door or turn the stove o. In addition, most of us
occasionally engage in repetitive or stereotyped behavior,
such as checking the stove or the lock on the door or step-
ping over cracks on a sidewalk. One recent study found
that more than 25 percent of people in the United States
report experiencing obsessions or compulsions at some
time in their lives (Ruscio et al., 2010). With OCD, how-
ever, the thoughts are excessive and much more persistent
and distressing, and the associated compulsive acts inter-
fere with everyday activities. Diagnosis requires that
obsessions and compulsions take at least 1 hour per day,
and in severe cases they may take most of the person’s
waking hours. It is important to note that normal and
abnormal obsessions and compulsive behaviors exist on a
continuum, diering in the frequency and intensity of the
obsessions and in the degrees to which the obsessions and
compulsions are resisted and are troubling (Steketee &
Barlow, 2002).
The common themes of OCD typically involve cleaning, symmetry,
taboo thoughts, and harm.
Werner Muenzker/Shutterstock
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Panic, Anxiety, Obsessions, and Their Disorders 217
Washing or cleaning rituals vary from relatively mild
ritual-like behavior such as spending 15 to 20 minutes
washing one’s hands after going to the bathroom, to more
extreme behavior such as washing one’s hands with disin-
fectants for hours every day to the point where the hands
bleed. Checking rituals also vary in severity from relatively
mild (such as checking all the lights, appliances, and locks
two or three times before leaving the house) to very
extreme (such as going back to an intersection where one
thinks one may have run over a pedestrian and spending
hours checking for any sign of the imagined accident,
much as Mark does in the case study). Both cleaning and
checking rituals are often performed a specific number of
times and thus also involve repetitive counting. The
committed, and he could not mail a letter for the same reason. He
also could not go into a store alone or into public bathrooms, where
he feared he might write a confession on the wall and be caught
and punished.
As we have noted, people with OCD feel compelled to
perform acts repeatedly that often seem pointless and
absurd even to them and that they in some sense do not
want to perform. There are five primary types of compul-
sive rituals: cleaning (hand washing and showering),
checking, repeating, ordering or arranging, and counting
(Antony et al., 1998; Mathews, 2009), and many people
exhibit multiple kinds of rituals. For a smaller number of
people, the compulsions are to perform various everyday
acts (such as eating or dressing) extremely slowly (primary
obsessional slowness), and for others the compulsions are
to have things exactly symmetrical or “evened up”
(Mathews, 2009; Steketee & Barlow, 2002).
Many of us show some compulsive behavior, but people with OCD
feel compelled to perform repeatedly some action in response to an
obsession, in order to reduce the anxiety or discomfort created by the
obsession. Although the person may realize that the behavior is
excessive or unreasonable, he or she does not feel able to control the
urge. Obsessive-compulsive hand washers may spend hours a day
washing and may even use abrasive cleansers to the point that their
hands bleed.
Voronin76/Shutterstock
performance of the compulsive act or the ritualized series
of acts usually brings a feeling of reduced tension and sat-
isfaction, as well as a sense of control, although this anxiety
relief is typically fleeting. This is why the same rituals need
to be repeated over and over (Purdon, 2009; Steketee &
Barlow, 2002).
Prevalence, Age of Onset,
and Gender Dierences
Approximately 2 to 3 percent of people meet criteria for
OCD at some point in their lifetime, and approximately 1
percent meet criteria in a given year (Ruscio et al., 2010).
Over 90 percent of treatment-seeking people with OCD
experience both obsessions and compulsions (Foa &
Kozak, 1995; Franklin & Foa, 2007). When mental rituals
and compulsions such as counting are included as compul-
sive behaviors, this figure jumps to 98 percent.
Divorced (or separated) and unemployed people are
somewhat overrepresented among people with OCD
( Torres et al., 2006), which is not surprising given the great
diculties this disorder creates for interpersonal and occu-
pational functioning. Some studies showed little or no gen-
der dierence in adults, which would make OCD quite
dierent from most of the rest of the anxiety disorders.
However, one British epidemiological study found a
gender ratio of 1.4 to 1 (women to men; Torres et al.,
2006). OCD typically begins in late adolescence or early
Howard Stern, a famous radio personality and author, as with other
people who have suered from OCD, found relief in a compulsive
act or ritualized series of acts to bring about a feeling of reduced
tension and a sense of control. In his book Miss America, Stern
describes behaviors such as turning pages in magazines only with his
pinky finger, walking through doors with the right side of his body
leading, and flipping through television stations in a particular order
before turning the set o.
Desiree Navarro/Everett Collection/Alamy
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218 Chapter 6
was allowed to engage in the compulsive ritual immedi-
ately after the provocation, however, her or his anxiety
would generally decrease rapidly (although only tempo-
rarily) and therefore reinforce the compulsive ritual.
This model predicts, then, that exposure to feared
objects or situations should be useful in treating OCD if the
exposure is followed by prevention of the ritual, enabling
the person to see that the anxiety will subside naturally in
time without the ritual (see also Rachman & Shafran, 1998).
This is indeed the core of the most eective form of behav-
ior therapy for OCD, as discussed later. Thus, the early
behavioral model has been very useful in helping us
understand what factors maintain obsessive-compulsive
behavior, and it has also generated an eective form of
treatment. However, it has not been so helpful in explain-
ing why people with OCD develop obsessions in the first
place and why some people never develop compulsive
behaviors.
OCD AND PREPAREDNESS The preparedness concept
described earlier that considers the evolutionarily adaptive
nature of fear and anxiety for our early ancestors also can
help us to understand the occurrence and persistence of
OCD (De Silva, Rachman, & Seligman, 1977; Rapoport,
1989). The fact that many people with OCD have obses-
sions and compulsions focused on dirt, contamination, and
other potentially dangerous situations has led many
researchers to conclude that these features of the disorder
likely have deep evolutionary roots (Mineka & Zinbarg,
1996, 2006). In addition, some theorists have argued that
the displacement activities that many species of animals
engage in under situations of conflict or high arousal
resemble the compulsive rituals seen in obsessive-
compulsive disorder (Craske, 1999; Mineka & Zinbarg,
1996; Rapoport, 1989; Winslow & Insel, 1991). Displace-
ment activities often involve grooming (such as a bird
preening its feathers) or nesting under conditions of high
conflict or frustration. They may therefore be related to the
distress-induced grooming (such as washing) or tidying
rituals seen in people with OCD, which are often provoked
by obsessive thoughts that elicit anxiety.
THE EFFECTS OF ATTEMPTING TO SUPPRESS OBSES-
SIVE THOUGHTS Quick, don’t think about a white
bear! Gotcha. When most people attempt to suppress
unwanted thoughts they sometimes experience a para-
doxical increase in those thoughts later (Wegner, 1994). As
already noted, people with normal and abnormal obses-
sions dier primarily in the degree to which they resist
their own thoughts and find them unacceptable. Thus,
one factor contributing to the frequency of obsessive
thoughts, and the negative moods with which they are
often associated, may be these attempts to suppress them
(similar to what was discussed earlier about the eects of
attempts to control worry in people with GAD). For
adulthood, but also can occur in children, where its
symptoms are strikingly similar to those of adults (Poulton
et al., 2009; Torres et al., 2006). Childhood or early adoles-
cent onset is more common in boys than in girls and is
often associated with greater severity (Lomax et al., 2009)
and greater heritability (Grisham et al., 2008). In most cases
the disorder has a gradual onset, and once it becomes a
serious condition, it tends to be chronic, although the
severity of symptoms sometimes waxes and wanes over
time (Mataix-Cols et al., 2002).
Comorbidity with Other Disorders
OCD frequently co-occurs with other anxiety disorders,
most commonly social anxiety, panic disorder, GAD, and
PTSD (Kessler, Chiu, Demler, et al., 2005; Mathews, 2009).
Moreover, approximately 25 to 50 percent of people with
OCD experience major depression at some time in their
lives and as many as 80 percent experience significant
depressive symptoms (Steketee & Barlow, 2002; Torres et
al., 2006), often at least partly in response to having OCD.
Psychological Causal Factors
The following psychological factors may cause obsessive-
compulsive disorder.
OCD AS LEARNED BEHAVIOR The dominant behav-
ioral or learning view of obsessive-compulsive disorder is
derived from Mowrer’s two-process theory of avoidance
learning (1947). According to this theory, neutral stimuli
become associated with frightening thoughts or experi-
ences through classical conditioning and come to elicit
anxiety. For example, touching a doorknob or shaking
hands might become associated with the “scary” idea of
contamination. Once having made this association, the
person may discover that the anxiety produced by shaking
hands or touching a doorknob can be reduced by hand
washing. Washing his or her hands extensively reduces the
anxiety, and so the washing response is reinforced, which
makes it more likely to occur again in the future when
other situations evoke anxiety about contamination (Rach-
man & Shafran, 1998). Once learned, such avoidance
responses are extremely resistant to extinction (Mineka &
Zinbarg, 2006). Moreover, any stressors that raise anxiety
levels can lead to a heightened frequency of avoidance
responses in animals or compulsive rituals in humans
(Cromer et al., 2007).
Several classic experiments conducted by Rachman
and Hodgson (1980) supported this theory. They found
that for most people with OCD, exposure to a situation that
provoked their obsession (e.g., a doorknob or toilet seat for
someone with obsessions about contamination) did indeed
produce distress, which would continue for a moderate
amount of time and then gradually dissipate. If the person
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