Given their often bizarre appearance, compulsions are often difficult to understand. Why would an individual choose to engage in such behavior, and why does the behavior persist despite marked functional impairment and distress? Compulsions are best understood within the context of the function they serve. Learning theory models of OCD (e.g., Kozak & Foa, 1997) have traditionally been based to some extent on Mowrer's (1960) two-factor theory of fear. Briefly, two-factor theory posits that classically conditioned fear motivates avoidance behavior. When the organism avoids the feared stimulus successfully, anxiety is reduced and the avoidance is therefore negatively reinforced. The avoidance also prevents extinction of fear by limiting exposure to the feared stimulus; therefore, the fear is maintained. OCD theorists have suggested that compulsions are a form of active avoidance, which are cued by obsessive fears. When the individual performs a compulsion, fear is reduced. Thus, compulsions are negatively reinforced, and obsessive fear is increased. Although there is little evidence for the role of classical conditioning in OCD, studies have supported the anxiety-reduction hypothesis of compulsions: Exposure to feared stimuli increased participants'anxiety, whereas performing compulsions led to decreased anxiety (Hodgson & Rachman, 1972). One problem with a two-factor model of compulsions is the fact that some individuals with OCD report that compulsions are associated with increased, rather than decreased, fear. For example, Roper, Rachman, and Hodgson (1973) found that a subsample of compulsive checkers reported higher levels of fear after checking. Cases such as these might be better explained by Herrnstein's (1969) learning theory, which suggests that mildly anxiety-evoking behaviors might be considered avoidant if they serve to prevent the occurrence of strong anxiety. Thus, although checking may elicit anxiety in some patients, refraining from checking is perceived as even more aversive. In summary, the specific function of compulsions may vary, but the general function appears to be one of anxiety reduction and/or prevention. In this manner, compulsive behavior is negatively reinforced, and extinction of fear is blocked.
Attention to the function of compulsion may help with the differential diagnosis of OCD. Many DSM-IV impulse control disorders have been classified as part of an "OCD spectrum." These disorders include "compulsive" overeating, gambling, and sex. However, these problems tend to be functionally distinct from compulsions: They are not triggered by obsessions or fears and are not negatively reinforced by fear reduction. On the contrary, disinhibited behaviors are more likely to be triggered by feelings of tension or boredom, and because the behaviors are satisfying, they are positively, rather than negatively, reinforced (e.g., Steketee, 1993). Although Goldsmith, Shapira, Phillips, and McElroy (1998) point out that this distinction does not apply to every patient, until more convincing data are produced, the term compulsion is best reserved to indicate a specific functional relationship between behavior and fear.
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