Paired Association and Classical Conditioning
At this point we introduce a particular type of learning called classical conditioning. Specifically we will discuss the concept of paired association and its relationship to the development of anxiety disorders. However, classical conditioning is discussed in greater detail in the section on Behavioral Models and Associated Therapies. Classical conditioning can be applied to understand many learning experiences. But for our purposes, we will limit our discussion to classical conditioning as it relates to how anxiety disorders may be learned.
Classical conditioning refers to a type of learning that occurs when anxiety becomes a learned response via a process called paired association. Paired association refers to the pairing of anxiety symptoms with a neutral stimulus. A neutral stimulus can be any situation, event, or object that is does not ordinarily elicit a fearful response. In the previous example, the grocery store would be a neutral stimulus. By pairing the anxiety symptoms of an uncued panic attack, with the neutral stimulus (the grocery story), anxiety now becomes associated with the neutral stimulus. Thus, a previously neutral stimulus (the grocery store) now evokes an anxious response. As a result of this pairing, the "neutral" stimulus which was previously considered non-threatening, subsequently becomes capable of automatically causing a fearful response because the person has "learned" it was a cue to a threat: The person has learned to be anxious via classical conditioning. Once this learning has occurred, the previously neutral stimulus (the grocery store) becomes a conditioned stimulus which now spontaneously evokes a fear response. The grocery store now prompts a cued panic attack due to the learning which took place; i.e., the grocery store now serves as a cue for danger.
In the example above, the grocery store became a conditioned stimulus which subsequently prompted a cued panic attack. However, cued panic attacks may also begin to form when people equate the physical symptoms of anxiety, with danger, even though the symptoms themselves are not dangerous. Recall that initial, uncued panic attacks are often viewed by the person as "coming out of the blue" without any observable trigger. Because the person experienced a significant amount of distress and discomfort when the symptoms of the attack first occurred, the symptoms themselves now represent a threat, and become a cue capable of triggering anxiety whenever the symptoms begin. In other words, the individual has now "learned" to fear the symptoms themselves, as well as any situation which might trigger the symptoms.
In order to illustrate these concepts, let's return to the previous example of someone who experienced an initial, uncued, panic attack in a grocery store. Recall, it is thought these initial panic attacks occur in response to some life stressor that is often outside the person's immediate awareness. Perhaps this person is experiencing some overall financial stress, such that shopping for groceries triggers this stress. So while shopping for groceries they suddenly feel short of breath and dizzy, they sense their heart is racing, and they become alarmed by these sensations because they just seem to "come out of the blue" for no apparent reason. Because of the learning that occurs through classical conditioning, future experiences of a racing heart with dizziness, and a grocery store, may each elicit an anxious response.
In addition to setting the stage for future, cued panic attacks, classical conditioning (via paired association) is often associated with development of phobias where certain objects or certain situations, not previously feared, now cause people to experience anxiety when in their presence. For example, imagine a child is happily playing with her neighbor's dog. However, while playing, the child accidentally pulls on the dog's tail a little too hard and as a result, the dog begins to bark and growl at her. At this point, the reaction from the dog may startle the young child and result in her experiencing some form of distress. If this type of experience with a dog were repeated several times, the child would come to associate dogs with her distress and may now wish to avoid all dogs, at all cost. Because all dogs are avoided, the child has no chance to experience dogs which do not bark or growl. Because she lacks any experience with kinder and gentler dogs, she has no information to refute her belief that all dogs are dangerous, and thus her fear is maintained. As we will see in the next section, while paired association plays a role in the development of anxiety disorders, avoidance plays a key role in maintaining those disorders.