PSYC 360 Chapter 7: Obsessive-Compulsive-Related and Trauma-Related Disorders

obsessions

intrusive and recurring thoughts, images, or impulses that are persistent and uncontrollable (i.e., the person cannot stop the thoughts) and that often appear irrational to the person experiencing them

body dysmorphic disorder

- preoccupation with imagined flaw in one's appearance - excessive repetitive behaviors or acts regarding appearance (e.g., checking appearance, seeking reassurance)

treatments that work for OCD, BDD, and hoarding disorder are similar:

- each of these disorders responds to antidepressant medications - the major psychological approach is exposure and response prevention, although this treatment is tailored for the specific conditions

hoarding disorder

- acquisition of an excessive number of objects - inability to part with those objects - spend a good deal of their time repetitively thinking about their current and potential future possessions

medications for obsessive-compulsive and related disorders

- antidepressants are the most commonly used medications for these disorders - in the treatment of OCD, clomipramine (Anafranil) is the most commonly used antidepressant

etiology of body dysmorphic disorder

- cognitive model: people with BDD tend to be detail oriented, and this influences how they look at features; instead of considering the whole, they examine one feature at a time, which makes it more likely that they will become engrossed in considering a small flaw; they also consider attractiveness to be vastly more important than do control participants

exposure and response prevention (ERP)

- developed by Victor Meyer (1966) by tailoring the exposure treatment of anxiety disorders to address the compulsive rituals that people with OCD use to ward off threats - people expose themselves to situations that elicit the compulsive act and then refrain from performing the compulsive ritual - the exposure component uses an exposure hierarchy - 25% of clients refuse ERP treatment - highly effective in reducing obsessions and compulsions; more effective than clomipramine

etiology of hoarding disorder

- evolutionary perspective: adaptive to stockpile vital resources - cognitive behavioral model suggests a number of factors that might make the adaptive behavior so uncontrollable: poor organizational abilities, unusual beliefs about possessions (extreme emotional attachment; seeing objects as core to their sense of self and identity), and avoidance behaviors (avoid organizing)

psychological treatment of PTSD

- exposure treatment is the primary psychological approach - the client is asked to face his/her worst fears, typically working up an exposure hierarchy - goals: extinguish fear response; challenge the idea that the person could not cope with the anxiety and fear generated by those stimuli - the focus is on memories and reminders of the original trauma (inc. in vivo exposure, imaginal exposure, virtual reality) - EMDR controversy - addition of emotion regulation skills teaching leads to positive gains - several cognitive strategies have been used to supplement exposure treatment for PTSD: bolster beliefs in ability to cope with initial trauma; cognitive processing therapy to help dispute tendencies toward self-blame - a growing number of websites and support groups provide social support for those recovering from traumatic experiences

ERP and BDD

- exposure: clients might be asked to interact with people who could be critical of their looks - response prevention: clients are asked to avoid activities they engage in to reassure themselves about their appearance, such as looking in mirrors - supplemented with strategies to address the cognitive features of the disorder, such as the excessively critical evaluations of physical features and the belief that self-worth depends on appearance

ERP and hoarding disorder

- exposure: focuses on getting rid of objects via anxiety hierarchy - response prevention: centers on halting the rituals engaged in to reduce anxiety, such as counting or sorting their possessions - despite common elements, treatment is tailored in many ways for hoarding: ex. since many people with hoarding disorder don't realize the gravity of their problems, motivational strategies are used to facilitate insight; once people decide to change, therapists help them make decisions about their objects and can provide tools and strategies to help organize/remove clutter - often supplement office sessions with in-home visits - self-help groups, supplemented with structured readings, have been found to be a helpful approach that is less expensive than individual therapy

cognitive behavioral models of obsessions and compulsions

- for those with OCD, previously functional responses for reducing threat become habitual and hence difficult to override after the threat is gone - once someone with OCD develops a conditioned response to a stimulus, they are slower to change their response to that stimulus after it is no longer rewarded - OCD is related to a deficit in the intuitive sense of feeling security and closure; anxious internal sense that things are not complete; compulsions are reinforcing because they help relieve this sensation - biologically based deficit in yedasentience

comorbidity for obsessive-compulsive and related disorders

- high rates of comorbidity within the three syndromes - all three syndromes also tend to co-occur with depression and anxiety disorders - OCD and BDD also tend to co-occur with substance use disorders

in the DSM-5, the symptoms for PTSD are grouped into four major categories:

- intrusively reexperiencing the traumatic event - avoidance of stimuli associated with the event - negative mood and thought that developed after trauma - increased arousal and reactivity

critical incident stress debriefing (CISD) & controversy

- involves immediate treatment of trauma victims within 72 hours of the traumatic event; given regardless of whether the person has developed symptoms - therapists encourage people to remember the details of the trauma and to express their feelings as fully as they can - highly controversial: a review of six studies found that those who received CISD tended to fare worse

deep brain stimulation: a treatment in development for OCD

- involves implanting electrodes into the brain, for OCD: typically implanted into either the nucleus accumbens or a region at the margin of the ventral striatum - researchers do this as a last-plan; for those with chronic OCD that fail to respond even after multiple pharmacological treatments

BDD vs. eating disorders

- most people with BDD are concerned about several different aspects of their appearance - when shape and weight concerns are the only foci, clinicians should consider whether the symptoms are better explained by an eating disorder

DSM-5 criteria for obsessive-compulsive disorder

- obsessions and/or compulsions - obsessions are defined by: + recurrent, intrusive, persistent, unwanted thoughts, urges, or images + the person tries to ignore, suppress, or neutralize the thoughts, urges, or images - compulsions are defined by: + repetitive behaviors or thoughts that the person feels compelled to perform to prevent distress or a dreaded event + the person feels driven to perform the repetitive behaviors or thoughts in response to obsessions or according to rigid rules + the acts are excessive or unlikely to prevent the dreaded situation - the obsessions or compulsions are time consuming (e.g., at least 1 hour per day) or cause clinically significant distress or impairment

medication treatment of PTSD

- one class of antidepressant, the selective serotonergic reuptake inhibitors (SSRIs), has received strong support as a treatment - relapse is common if medications are discontinued

OCD, body dysmorphic disorder, and hoarding disorder share some overlap in etiology that is particularly apparent for genetic and neurobiological risk factors:

- people with BDD and hoarding disorder often have a family history of OCD, which could be the result of a shared genetic vulnerability - the three disorders seem to involve some of the same brain regions

DSM-5 criteria for hoarding disorder

- persistent difficult discarding or parting with possessions, regardless of their actual value - perceived need to save items - distress associated with discarding - the symptoms result in the accumulation of a large number of possessions that clutter active living spaces to the extent that their intended use is compromised unless others intervene

DSM-5 criteria for body dysmorphic disorder

- preoccupation with one or more perceived defects in appearance - others find the perceived defect(s) slight or unobservable - the person has performed repetitive behaviors or mental acts (e.g., mirror checking, seeking reassurance, or excessive grooming) in response to the appearance concerns - preoccupation is not restricted to concerns about weight or body fat

obsessive-compulsive disorder

- repetitive, intrusive, uncontrollable thoughts or urges (obsessions) - repetitive behaviors or mental acts that the person feels compelled to perform (compulsions)

psychological treatment of acute stress disorder

- short-term cognitive behavioral approaches that include exposure appear to help prevent the development of PTSD - exposure treatment appears more effective than cognitive restructuring in preventing the development of PTSD

culture may shape the risk for PTSD in several ways

- some cultural groups may be exposed to higher rates of trauma (seems to be the case for minority populations in the US) - culture may shape the types of symptoms observed in PTSD (ex. Ataque de nervios of Puerto Rico involves physical symptoms and fears of going crazy in the aftermath of severe stress and thus is similar to PTSD)

thought suppression: a cognitive model of obsessions

- suggests that people with OCD may try harder to suppress their obsessions than other people and, in doing so, may actually make the situation worse - people with OCD tend to believe that thinking about something can make it more likely to occur, and are likely to describe especially deep feelings of responsibility for what occurs - therefore, they are more likely to attempt thought supression - white bear: trying to suppress a thought may have the paradoxical effect of inducing preoccupation with it

the ASD diagnosis is not as well accepted as the PTSD diagnosis; two major concerns:

- the diagnosis could stigmatize short-term reactions to serious traumas, even though these are quite common - most people who go on to meet diagnostic criteria for PTSD do not experience DSM-IV-TR diagnoses of ASD in the first month after the trauma (however, those who experience ASD are at elevated risk of developing PTSD within 2 years)

brain-imaging studies indicate that three closely related areas of the brain are unusually active in people with OCD:

- the orbitofrontal cortex (an area of the medal prefrontal cortex located just above the eyes) - the caudate nucleus (part of the basal ganglia) - the anterior cingulate when people with OCD are shown objects that tend to provoke symptoms, activity in these three areas increases (a similar pattern in orbitofrontal cortex and caudate nucleus emerges when people with BDD view pictures of their face; a similar pattern in orbitofrontal cortex and anterior cingulate emerges when people with hoarding disorder are faced with decisions about whether to keep or discard possessions such as old mail)

nature of the trauma: severity and the type of trauma matter

- the severity of the trauma influences whether or not a person will develop PTSD - traumas caused by humans are more likely to cause PTSD than are natural disasters

the obsessive-compulsive and related syndromes often co-occur

- ~ 1/3 of people with body dysmorphic disorders meet diagnostic criteria for OCD during their lifetime - up to 1/4 of people with hoarding disorder will meet diagnostic criteria for OCD - ~ 1/3 of people with OCD experience at least some symptoms of hoarding

lifetime prevalence estimates for obsessive-compulsive and related disorders

- ~2% for OCD and for BDD - 1.5% for hoarding disorder - OCD and BDD slightly more common along women than men - hoarding equally common among men and women, but very few men seek treatment

about _____ of people with BDD endorse some history of suicidal ideation, and about _____ have attempted suicide

1/3; 20%

as many as _____ with BDD endure plastic surgery, and many withstand multiple surgeries

1/5 unfortunately, plastic surgery does so little to allay their concerns that many report wanting to sue or hurt their physicians after the surgery

OCD tends to begin either before age ____ or else in ____________

10; late adolescence/early adulthood

on average, people with BDD think about their appearance for _______ hours per day

3-8

heritability is estimated to account for _________ of the variance in whether OCD, hoarding, and body dysmorphic conditions develop

40-50%

DSM-5 criteria for posttraumatic stress disorder

A. exposure to actual or threatened death, serious injury, or sexual violence, in one or more of the following ways: experiencing the event personally, witnessing the event in person, learning that a violent or accidental death or threat of death occurred to a close other, or experiencing repeated or extreme exposure to aversive details of the event(s) other than through the media B. at least 1 of the following intrusion symptoms: - recurrent, involuntary, and intrusive distressing memories of the trauma(s), or in children, repetitive play regarding the trauma themes - recurrent distressing dreams related to the event(s) - dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the trauma(s) were recurring, or in children, reenactment of trauma during play - intense or prolonged distress or physiological reactivity in response to reminders of the trauma(s) C. at least 1 of the following avoidance symptoms: - avoids internal reminders of the trauma(s) - avoids external reminders of the trauma(s) D. at least 2 of the following negative alterations in cognitions and mood began after the event: - inability to remember an important aspect of the trauma(s) - persistent and exaggerated negative beliefs or expectations about one's self, others, or the world - persistently excessive blame of self or others about the trauma(s) - persistently negative emotional state, or in children younger than 7, more frequent negative emotions - markedly diminished interest or participation in significant activities - feeling of detachment or estrangement from others, or in children younger than 7, social withdrawal - persistent inability to experience positive emotions E. at least 2 of the following changes in arousal and reactivity: - irritabile or aggressive behavior - reckless or self-destructive behavior - hypervigilance - exaggerated startle response - problems with concentration - sleep disturbance F. the symptoms began or worsened after the trauma(s) and continued for at least one month G. among children younger than 7, diagnosis requires criteria A, B, E, and F, but only 1 symptom from either category C or D

brain-imaging studies show that the volume of the _________ is smaller among people with PTSD than among those who do not have the condition

PTSD (twin studies show that smaller-than-average hippocampal volume probably precedes the onset of the disorder)

the aftermath of the ________ spurred the development of the PTSD diagnosis

Vietnam War

BDD typically begins in _________

adolescence

many of the risk factors for PTSD overlap with the risk factors for ___________

anxiety disorders ex. PTSD appears to be related to genetic risk for anxiety disorders, high levels of activity in areas of the fear circuit such as the amygdala, childhood exposure to trauma, and tendencies to attend selectively to cues of threat; neuroticism and negative affectivity predict the onset of PTSD; has been related to Mowrer's two-factor model of conditioning

several types of studies suggest that people who cope with a trauma by trying to _________ are more likely than others to develop PTDS

avoid thinking about it

to cope wth the intense shame they feel about their appearance, people with BDD may avoid ___________

contact with others

cognitive approaches to OCD focus on...

challenging people's beliefs about what will happen if they do not engage in rituals or challenging their often inflated sense of responsibility; eventually, to help test such beliefs, these approaches will use exposure

hoarding behavior usually begins in ____________

childhood or early adolescence (these early symptoms may be kept under control by parents and by limited outcome, so severe impairment from the hoarding often does not surface until later in life; animal hoarding often does not emerge until middle age or older)

longitudinal research suggests that for most people, OCD symptoms tend to be fairly _______

chronic

the symptoms of PTSD may develop soon after the trauma but sometimes do not develop for years after the initial event; once PTSD develops, symptoms are relatively _______

chronic

in has been argued that prolonged exposure to trauma, such as repeated childhood abuse, might lead to a broader range of symptoms than those covered by the DSM criteria for PTSD; this syndrome has been referred to as ____________

complex PTSD

OCD pattern of symptoms appears to be similar across ________

cultures

yedasentience

defined as the subjective feeling of knowing that you have thought enough, cleaned enough, or in other ways done what you should to prevent chaos and danger from low-level threats in the environment

acute stress disorder (ASD)

diagnosed when symptoms occur after a trauma; symptoms are fairly similar to those of PTSD, but the duration is shorter; this diagnosis is only applicable when the symptoms last for 3 days to one month

much of the work on avoidance coping focuses on symptoms of _________

dissociation (such as feeling removed from one's body or emotions or being unable to remember the event)

people who have symptoms of __________ during and immediately after the trauma are more likely to develop PTSD, as are people who try to _________ memories of the trauma

dissociation; suppress

posttraumatic stress disorder (PTSD)

entails an extreme response to a severe stressor, including recurrent memories of the trauma, avoidance of stimuli associated with the trauma, negative emotions and thoughts, and symptoms of increased arousal

the most widely used psychological treatment for the obsessive-compulsive and related disorders is ____________

exposure and response prevention (ERP)

obsessive-compulsive and related disorders

group of overlapping disorders listed in the DSM-5 that involves repetitive thoughts and behaviors that are so extreme that they interfere with everyday life

two particularly important protective factors which may help a person cope with severe traumas more adaptively inc:

high intelligence and strong social support

trauma-related disoders

inc. posttraumatic stress disorder and acute stress disorder, two conditions that are triggered by exposure to severely traumatic events

hippocampus

plays a central role in our ability to locate autobiographical memories in space, time, and context, and in organizing our narratives of those memories

compulsions

repetitive, clearly excessive behaviors or mental acts that the person feels driven to perform to reduce the anxiety caused by obsessive thoughts or to prevent some calamity from occurring

________________ factors surely play a role in how people decide whether they are attractive, but among those who develop BDD, case reports from around the world suggest that the symptoms and outcomes are similar across _________; the body part that becomes a focus of concern sometimes differs by ________, though

social and cultural; cultures; culture

eye movement desensitization and reprocessing (EMDR) & controversy

the client recalls a scene related to the trauma while visually tracking the therapist's fingers as the therapist moves them back and forth controversy: some think the fingers don't do anything; it's just like wearing a purple hat and doing exposure therapy

PTSD tends to be highly comorbid with other conditions

the most common comorbid disorders are other anxiety disorders, major depression, substance abuse, and conduct disorder

among people exposed to a trauma, women are ________ to develop PTSD as are men

twice as likely

many people who hoard are __________ of the severity of their behavior, but to those surrounding them, the consequences of hoarding are clear and sometimes seem quite severe

unaware