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Paired Association and Classical Conditioning

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D. Updated: Jun 4th 2019

We now 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 more detail in the section on Behavioral Learning Theories and Associated Therapies. Classical conditioning can be applied to understand many learning experiences. For our purposes, we will limit our discussion to classical conditioning as it relates to how anxiety disorders may be learned.

upset womanAnxiety can be learned through a type of learning called classical conditioning. This occurs 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. Because of this pairing, the "neutral" stimulus, which was previously considered non-threatening, subsequently becomes capable of automatically causing a fearful response. This is 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 that spontaneously evokes a fear response. The grocery store now prompts a cued panic attack due to the learning that took place. In other words, the grocery store now serves as a cue for danger.

In the example above, the grocery store became a conditioned stimulus that 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. It is important to remember the symptoms themselves are not actually dangerous. Recall that a person sees initial uncued panic attacks as "coming out of the blue" without any observable trigger. Because the person experienced a significant amount of distress and discomfort when the attack first occurred, the symptoms themselves now represent a threat. The symptoms 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 that might trigger the symptoms. This creates a vicious cycle: Anxiety triggers a panic attack. The symptoms signal more danger. This is turn creates more anxiety and so on.

In order to illustrate these concepts, let's return to the previous example of the woman in the grocery store who has an uncued, panic attack. Recall, these initial panic attacks frequently occur in response to some life stressor. However, these stressors are often outside the her immediate awareness. Perhaps this woman is experiencing some overall financial stress, maybe she recently lost their job. The need to shop for groceries triggers this stress. While shopping for groceries she suddenly feel short of breath and dizzy. She senses their heart is racing. These sensations are alarming 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 the development of phobias. Phobias are highly anxious responses to specific objects or situations. 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. 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. She might experience 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. As such, she may now wish to avoid all dogs, at all cost. Because she avoids all dogs, the child has no chance to experience dogs that 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. 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.


Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute

Authors Statement: Established in 1979, the Bio Behavioral Institute is a psychological and psychiatric clinic dedicated to the treatment and research of anxiety and mood disorders. Based in Long Island, NY, USA, the institute serves both a local and international clientele. Our staff have over 40 years of experience treating anxiety and mood disorders and have been at the forefront of scientifically supported treatments for anxiety disorders for many years. We offer a variety of programs provided by a multidisciplinary team of professionals. For more information, please visit us online at or view Bio Behavioral Institute and author biographical information on this website.

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