What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (46 page)

7
. L. Ost, U. Steiner, and J. Fellenius, “Applied Tension, Applied Relaxation, and the Combination in the Treatment of Blood Phobia,”
Behaviour Research and Therapy 2.7
(1989): 109–21. More recent reports suggest close to 100 percent cure with this procedure.

8
. There are few noncase report studies of cognitive therapy for phobias. Those that exist show gains, but behavior therapy is added, so it is not possible to sort out any additional usefulness of the cognitive component. There are undeniable cognitive distortions in phobias, but I doubt that they can be countered directly by cognitive techniques. See G. Thorpe, J. Hacker, L. Cavallaro, and G. Kulberg, “Insight Versus Rehearsal in Cognitive-Behaviour Therapy: A Crossover Study with Sixteen Phobics,”
Behavioural Psychotherapy
15 (1987): 319–36.

9
. In one study, 79 percent of agoraphobic patients who received cognitive therapy plus extinction for panic were panic free, as against only 39 percent with extinction alone. In L. Michelson and K. Marchione, “Cognitive, Behavioral, and Physiologically-based Treatments of Agoraphobia: A Comparative Outcome Study.” Paper presented at the annual meeting of the American Association for the Advancement of Behavior Therapy, Washington, D.C., November 1989.

R. Mattick and L. Peters, “Treatment of Severe Social Phobia: Effects of Guided Exposure With and Without Cognitive Restructuring,”
Journal of Consulting and Clinical Psychology
56 (1988): 251–60, suggest possible benefits of cognitive therapy with social phobias as well.

10
. There are about a half dozen reasonably well done recent studies of the effects of various drugs on social phobias. See J. Gorman and L. Gorman, “Drug Treatment of Social Phobia,”
Journal of Affective Disorders
13 (1987): 183–92; A. Levin, F. Scheier, and M. Liebowitz, “Social Phobia: Biology and Pharmacology,”
Clinical Psychology Review
9 (1989): 129–40; M. Versiani, F. Mundim, A. Nardi, et al., “Tranycypromine in Social Phobia,”
Journal of Clinical Psychopharmacology
8 (1988): 279–83; M. Liebowitz, J. Gorman, A. Fryer, et al., “Pharmacotherapy of Social Phobia: An Interim Report of a Placebo-Controlled Comparison of Phenelzine and Atenolol,”
Journal of Clinical Psychiatry
49 (1988): 252–57; J. Reich and W. Yates, “A Pilot Study of the Treatment of Social Phobia with Alprazolam,”
American Journal of Psychiatry
145 (1988): 590–94; and M. Liebowitz, R. Campeas, A. Levin, et al., “Pharmacotherapy of Social Phobia,”
Psychosomatics
28 (1987): 305–8.

Most of these studies show a 60 to 75 percent level of improvement with drugs (the MAO inhibitors are particularly effective). Unfortunately, most of these studies do not report what happens to the patients after drugs are discontinued. Those that do (Versiani et al., “Tranycypromine in Social Phobia;” Reich and Yates, “A Pilot Study”) report very high relapse rates. R. Noyes, D. Chaudry, and D. Domingo, “Pharmacologic Treatment of Phobic Disorders,”
Journal of Clinical Psychiatry
47 (1986): 445–52, review this literature and conclude with two major cautions: A high dropout rate with drugs and a high relapse rate after drug discontinuation are likely. It is on this basis that I conclude that the drugs have only a cosmetic effect on social anxiety.

11
. See C. Zitrin, D. Klein, M. Woerner, and D. Ross, “Treatment of Phobias I: Comparison of Imipramine Hydrochloride and Placebo,”
Archives of General Psychiatry
40 (1983): 125–38, versus I. Marks, S. Gray, D. Cohen, et al., “Imipramine and Brief Therapist-Aided Exposure in Agoraphobics Having Self-Exposure Homework,”
Archives of General Psychiatry
40 (1983): 153–62.

This is still rather a heated controversy, with the benefits of antidepressants alone and of exposure (extinction) alone in some doubt. One serious worry is the high relapse rate, perhaps over 50 percent, when drugs are stopped (see R. Noyes, M. Garvey, B. Cook, and L. Samuelson, “Problems with Tricyclic Anti-Depressant Use in Patients with Panic Disorder or Agoraphobia,”
Journal of Clinical Psychiatry
50 [1989]: 163–69). Similarly, extinction therapy alone has some lasting benefit five years after termination, with about 50 percent of patients doing well, but few completely well (see P. Lelliott, I. Marks, W. Monteiro, et al., “Agoraphobics 5 Years After Imipramine and Exposure: Outcome and Predictors,”
Journal of Nervous and Mental Diseases
175 [1987]: 599–605). So each alone has some lasting benefit but is far from a cure.

The combination of exposure and antidepressants looks like the least controversial treatment of choice. Improvement rate may be as high as 90 percent with the combination (see J. Ballenger, “Pharmacotherapy of the Panic Disorders,”
Journal of Clinical Psychiatry
47 [1986]: 27–32). In a particularly well executed study, only the combination group improved, with the agoraphobes who had either tricyclics alone or exposure alone not improving significantly (see M. Telch, S. Agras, C. Taylor, et al., “Combined Pharmacological and Behavioural Treatment for Agoraphobia,”
Behaviour Research and Therapy
23 [1985]: 325–35). For other well-executed combined drug-and-exposure studies, see M. Mavissakalian and L. Michelson, “Two-Year Follow-up of Exposure and Imipramine Treatment of Agoraphobia,”
American Journal of Psychiatry
143 (1986): 1106–12.

For a quantitative review of the drug and psychotherapy literatures in agoraphobia, see R. Mattick, G. Andrews, D. Hadzi-Pavlovic, and H. Christensen, “Treatment of Panic and Agoraphobia: An Integrative Review,”
Journal of Nervous and Mental Disease
178 (1990): 567–76.

12
. This case history comes from Isaac Marks, the leading contemporary British investigator of phobias.

13
. See M. Seligman, “Preparedness and Phobias,”
Behavior Therapy 2
(1971): 307–20; and S. J. Rachman and M. Seligman, “Unprepared Phobias: Be Prepared,”
Behaviour Research and Therapy
14 (1976): 333–38.

14
. A. Ohman, M. Fredrikson, K. Hugdahl, and P. Rimmo, “The Premise of Equipotentiality in Classical Conditioning: Conditioned Electrodermal Responses to Potentially Phobic Stimuli,”
Journal of Experimental Psychology: General
105 (1976): 313–37. For an articulate dissenter from the Ohman experiments and from the preparedness theory of phobias, see R. McNally, “Preparedness and Phobias: A Review,”
Psychological Bulletin
101 (1987): 283–303.

15
. L. Ost and K. Hugdahl, “Acquisition of Phobias and Anxiety Response Patterns in Clinical Patients,”
Behaviour Research and Therapy
21 (1981): 623–31

16
. S. Hygge and A. Ohman, “Modelling Processes in Acquisition of Fear: Vicarious Electrodermal Conditioning to Fear-Relevant Stimuli,”
Journal of Personality and Social Psychology
36 (1978): 271–79. For a beautifully done parallel experiment in nonhuman primates, see S. Mineka, M. Davidson, M. Cook, and R. Keir, “Observational Conditioning of Snake Fear in Rhesus Monkeys,”
Journal of Abnormal Psychology
93 (1984): 355–72.

17
. Snakes and spiders make for stronger CSs than guns and knives, although the latter are more dangerous in cultural—but not evolutionary—fact than the former. See E. Cook, P. Hodes, and P. Lang, “Preparedness and Phobias: Effects of Stimulus Content on Human Visceral Conditioning,”
Journal of Abnormal Psychology
95 (1986): 195–207.

CHAPTER
7
Obsessions

1
. As remembered from “What Do We Plant?,” by Henry Abbey (i 842–1911).

2
. So catchy is this ditty that I read it once in fifth grade (some forty years ago) and it has stayed with me—intact—ever since, making monthly appearances on my jingle channel. Mark Twain, “Punch, Brothers, Punch” (1876), in
The Complete Humorous Sketches and Tales of Mark Twain
, ed. Charles Neider (Garden City, N.Y.: Doubleday, 1961), 303.

Ethical considerations forbid my telling you the lyrics of the even catchier jingles.

3
. D. Barlett and J. Steele,
Empire: The Life, Legend, and Madness of Howard Hughes
(New York: Norton, 1979), 233.

4
. S. J. Rachman and R. Hodgson’s classic book
Obsessions and Compulsions
(New York: Appleton-Century-Crofts, 1980) remains the definitive behavioral work on the topic. The questionnaire from this book is reproduced with minor changes.

5
. Judith Rapoport,
The Boy Who Couldn’t Stop Washing
(New York: Plume, 1990), 90–91. The evidence for heritability that follows comes from M. Lenane, S. Swedo, H. Leonard, et al., “Psychiatric Disorders in First Degree Relatives of Children and Adolescents with Obsessive Compulsive Disorder,”
Journal of the American Academy of Child and Adolescent Psychiatry
29 (1990): 407–12.

6
. S. Turner, D. Beidel, and R. Nathan, “Biological Factors in Obsessive-Compulsive Disorders,”
Psychological Bulletin
97 (1985): 430–50; L. Baxter, M. Phelps, J. Mazziotta, et al., “Local Cerebral Glucose Metabolic Rates in Obsessive-Compulsive Disorder: A Comparison with Rates in Unipolar Depression and Normal Controls,”
Archives of General Psychiatry
44 (1987): 211–18; R. Rubin, J. Villanueva-Meyer, J. Ananth, et al., “Regional Xenon 133 Cerebral Blood Flow and Cerebral Technetium 99m HMPAO Uptake in Unmedicated Patients with Obsessive-Compulsive Disorder and Matched Normal Control Subjects,”
Archives of General Psychiatry
49 (1992): 695–702.

The latest studies show normalization of brain function with Anafranil (clomipramine) treatment, fluoxetine treatment, and behavior therapy. See C. Benkelfat, T. Nordahl, W. Semple, et al., “Local Cerebral Glucose Metabolic Rates in Obsessive-Compulsive Disorder,”
Archives of General Psychiatry
47 (1990): 840–48; L. Baxter, J. Schwartz, K. Bergman, et al., “Caudate Glucose Metabolic Rate Changes with Both Drug and Behavior Therapy for Obsessive-Compulsive Disorder,”
Archives of General Psychiatry
49 (1992): 681–89; S. Swedo, P. Pietrini, H. Leonard, et al., “Cerebral Glucose Metabolism in Childhood-Onset Obsessive-Compulsive Disorder,”
Archives of General Psychiatry
49 (1992): 690–94.

7
. Both Judith Rapoport, in
The Boy Who Couldn’t Stop Washing
, and Isaac Marks and Adolf Tobena, in “Learning and Unlearning Fear: A Clinical and Evolutionary Perspective,”
Neuroscience and Biobehavioral Reviews
14 (1990): 365–84, have argued for an evolutionarily prepared substratum of OCD.

8
. For recent studies of Anafranil (clomipramine), see M. Jenike, L. Baer, P. Summergrad, et al., “Obsessive-Compulsive Disorder: A Double-Blind, Placebo-Controlled Trial of Clomipramine in 27 Patients,”
American Journal of Psychiatry
146 (1989): 1328–30; R. Katz, J. DeVeaugh-Geiss, P. Landau, “Clomipramine in Obsessive-Compulsive Disorder,”
Biological Psychiatry
28 (1990): 401–14; M. Pato, T. Piggott, J. Hill, et al., “Controlled Comparison of Buspirone and Clomipramine in Obsessive-Compulsive Disorder,”
American Journal of Psychiatry
148 (1991): 127–29; and M. Mavissakalian, B. Jones, S. Olson, J. Perel, “Clomipramine in Obsessive-Compulsive Disorder: Clinical Response and Plasma Levels,”
Journal of Clinical Psychopharmacology
10 (1990): 261–68. See M. Trimble, “Worldwide Use of Clomipramine,”
Journal of Clinical Psychiatry
51 (1990): 51–54, for a review of eleven double-blind studies. Overall, slightly fewer than 50 percent of the patients are improved to subclinical levels, and perhaps 25 percent are almost symptom free.

For side effects and the high relapse rate after drug discontinuation, see M. Pato, R. Zohar-Kadouch, J. Zohar, D. Murphy, “Return of Symptoms After Discontinuation of Clomipramine in Patients with Obsessive-Compulsive Disorder,”
American Journal of Psychiatry
145 (1988): 1521–25, which shows an 80 percent relapse rate; T. Piggott, M. Pato, S. Bernstein, et al., “Controlled Comparisons of Clomipramine and Fluoxetine in the Treatment of Obsessive-Compulsive Disorder,”
Archives of General Psychiatry
47 (1990): 926–32, which shows a comparable effect for fluoxetine to clomipramine and comparable high relapse after drug discontinuation; and J. Greist, “Treating the Anxiety: Therapeutic Options in Obsessive-Compulsive Disorder,”
Journal of Clinical Psychiatry
51 (1990): 29–34.

For an articulate critique of the biological viewpoint, see P. DeSilva and S. J. Rachman,
Obsessive-Compulsive Disorder: The Facts
(Oxford: Oxford University Press, 1992), 53–54

9
. The woodworking-film experiment was reported by M. Horowitz, “Intrusive and Repetitive Thoughts After Experimental Stress,”
Archives of General Psychiatry
32 (1975): 1457–63.