Abnormal Psychology

Anxiety Disorders 309

the medication is tapered off and the behavioral method is continued. This form of

combined treatment may help minimize relapse when medication is stopped, com-

pared to medication alone (Ellison & McCarter, 2002; Foa et al., 2005).

Cognitive Methods: Cognitive Restructuring

The goal of cognitive methods is to reduce the irrationality and frequency of the

patient’s intrusive thoughts and obsessions (Clark, 2005). Cognitive restructuring

focuses on assessing the accuracy of these thoughts, making predictions based on

them (“If I don’t go back to check the locks, I will be robbed”), and testing whether

these predictions come to pass.

Although CBT for OCD hadn’t been suffi ciently developed during Hughes’s life-

time, consider how it might have been used: There were periods when Hughes daily

and “painstakingly used Kleenex to wipe ‘dust and germs’ from his chair, ottoman,

side table, and telephone. Sometimes he spent hours methodically cleaning the tele-

phone, going over the earpiece, mouthpiece, base, and cord with Kleenex, repeating

the cleaning procedure again and again, tossing the used tissues into a pile behind

his chair” (Bartlett Steele, 1979, p. 233). At the same time, though, he didn’t have

his sheets changed for months at a time; to make the sheets last longer, he laid paper

towels over them and slept on those. Moreover, he bathed only a few times a year.

Clearly, such behavior was at odds with rational attempts to protect against germs.

CBT would have focused on his overestimation of the probability of contracting an

illness and the irrationality of his precautions.

Targeting Social Factors: Family Therapy

Although psychological or neurological factors are the primary targets of treat-

ment for OCD, in some cases, social factors may also be addressed, for example,

through family therapy or consultation with family members. This aspect of treat-

ment educates family members about the patient’s treatment and its goals and helps

the family function in a more normal way. Family members and friends may have

spent years conforming their behavior to the patient’s illness (e.g., using clean tis-

sues when handing an object to the patient), and they may be afraid to change their

own behavior as the patient gets better, for fear of causing a relapse.

FEEDBACK LOOPS IN TREATMENT: Obsessive-Compulsive Disorder

As we’ve seen, medication can be effective in treating the symptoms of OCD (at least

as long as the patient continues to take it). Medication works by changing neurochem-

istry, which in turn affects thoughts, feelings, and behaviors. We’ve also seen that CBT

is effective. How does CBT have its effects? Could it be that therapy changes brain

functioning in the same way that medication does? Until recently, such questions could

not be answered. But neuroimaging has made it possible to begin to understand the

positive effects of both medication and CBT on people with OCD. The neuropsycho-

social approach leads us to examine the types of factors and their feedback loops (see

Figure 7.16).

For example, in one study, researchers used PET scans to assess brain function-

ing in two groups of OCD patients. One group was given behavior therapy and

the other group was given the SSRI fl uoxetine (Prozac), which can reduce OCD

symptoms. Both behavior therapy and Prozac decreased activity in a part of the

basal ganglia that is involved in automatic behaviors (the right caudate). Prozac

also affected activity in two parts of the brain involved in attention: the thalamus

and the anterior cingulate (Baxter et al., 1992). Later research replicated the effects

of behavior therapy on the brain (Schwartz et al., 1996).

In short, behavioral therapy or CBT changes the brain (neurological factor). As

the patient improves, personal relationships change (social factor): The time and en-

ergy that had gone into the compulsions can be diverted to relationships. Moreover,

the patient experiences mastery over the symptoms and develops hope and a new view

of himself or herself (psychological factors). In turn, this makes the patient more will-

ing to continue therapy, which further changes the brain, and so on, in a happy cycle

of mutual feedback loops among neurological, psychological, and social factors.

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