Chapter 7 - Obsessive Compulsive Related and Trauma Related Disorders

Obsessive compulsive and related disorders

disorders characterized by repetitive thoughts and behaviors that are so extreme they interfere with daily life

Prevalence of OCRDS

• OCD 2-3%

• hoarding 2.6%

• skin picking (excoriation) 2.5%

• trichotillomania 2%

• females more in adulthood, males more in childhood

• females: more contamination obsessions

• males: more sexual and religious obsessions

• african americans + asians: more contamination obsessions than whites

Types of OCRDS

• OCD

• body dysmorphic disorder

• hoarding disorder

• skin picking

• hair pulling

• substance induced OCD

• OCRD related to a medical condition

Characteristics of OCRDs

• affect: anxious

• cognitive: maladaptive beliefs about thoughts and control, response inhibition

• behavioral: repetitive behaviors, hoarding behaviors

• psychophysiological symptoms

OCD criteria

A.presence of obsessions, compulsions, or both

B. The obsessions or compulsions are time-consuming (e.g., take

more than 1 hour per day) or cause clinically significant distress or

impairment in important areas of functioning.

Rule Outs

C. The disturbance is not due to the direct physiological effects of a

substance

D. The disturbance is not due to the direct physiological effects of a

medical condition and is not better explained by the symptoms of

another mental disorder.

Obsessions

recurrent and persistent thoughts, urges, images that cause anxiety or distress, individual attempts to ignore or suppress thoughts or images

Compulsions

repetitive behaviors that an individual feels driven to perform in response to an obsession or rules, are not connected to what they are meant to neutralize in a realistic way

• belief that this will reduce anxiety/prevent something

Connection between obsessions and compulsions

obsessions and compulsions are not connected in a realistic way

OCD Facts

• obsessions and compulsions along a continuum

• 10-40% of children with OCD experience tic disorder

• similar across cultures

• treatments: SSRIs, exposure and response prevention therapy (CBT)

Body dysmorphic disorder

preoccupation with one or more imagined or exaggerated defects in their appearance

• women: worry about skin, hair, facial features

• men: height, muscle size

• thinking about appearance for 3-8 hrs/day

• 1/3rd of people with BDD have little insight into their views - don’t know thoughts are not normative

BDD criteria

A. Preoccupation with one or more perceived defects or flaws in physical

appearance that are not observable or appear slight to others.

B. At some point during the course of the disorder, the individual has performed

repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking,

reassurance seeking) or mental acts (e.g., comparing his or her appearance

with that of others) in response to the appearance concerns.

C. The preoccupation causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

D. The appearance preoccupation is not better explained by concerns with body

fat or weight in an individual whose symptoms meet diagnostic criteria for an

eating disorder.

Muscle Dysmporhia

a form of body dysmorphic disorder occurring almost exclusively in men and adolescent boys, consists of preoccupation with the idea that one’s body is too small or insufficiently lean or muscular

Hoarding Disorder

person has a compulsive need to acquire objects and extreme difficulty in disposing of objects

• more common in women

• can interfere with basic needs

• unaware of severity of behavior

• 10% face eviction

• animal hoarding common

Hoarding disorder criteria

A. Persistent difficulty discarding or parting with possessions, regardless of their

actual value.

B. This difficulty is due to a perceived need to save the items and to distress

associated with discarding them.

C. The difficulty discarding possessions results in the accumulation of possessions

that congest and clutter active living areas and substantially compromises their

intended use. If living areas are uncluttered, it is only because of the interventions

of third parties (e.g., family members, cleaners, authorities).

D. The hoarding causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning (including maintaining a safe

environment for self and others).

E. The hoarding is not attributable to another medical condition (e.g., brain injury,

cerebrovascular disease, Prader-Willi syndrome).

F. The hoarding is not better explained by the symptoms of another mental disorder

Trichotillomania

urge to pull out own hair

• 1-5% of college students

• more common in females

Excoriation

skin picking

• 1-5% prevalence rate

• treatment: behavioral habit reversal treatment (CBT)

Causes of OCD

• generalized biological vulnerability to anxiety

• neurobiological causes

• specific psychological vulnerability

Neurobiological causes of OCD

fronto-striatal circuits - higher brain activity when stimuli that provokes symptoms is shown

Specific psychological vulnerability for OCD

• early life experiences

• dangerous thoughts

• thought-action fusion

Distraction as a cause of OCD

temporarily reduce anxiety, increase frequency of thoughts

Cognitive model of obsessions

• trying to suppress obsessions makes them worse

• thought-action fusion beliefs

• engage in thought suppression to reduce negative thoughts

Thought-action fusion

1. thinking about something is equally as morally wrong as doing it

2. thinking about events makes them more likely to happen 

Causes of BDD

• appearance based teasing

• detail oriented personality

• same neurobiological influences as OCD

Causes of hoarding disorder

cognition

• impaired attention

• unusual beliefs about keeping possessions

• “seeing potential” in objects, emotional attachment to objects

Treatment of OCRDs

• cognitive behavioral treatments

• exposure and ritual prevention

• medications

Cognitive behavioral treatments for OCRDs

• teaches clients to test beliefs (cognitions) about what will happen in feared situations

• challenge beliefs by evaluating what actually happens

Exposure and ritual prevention for OCRDs

• rituals are prevented and client is systematically exposed to feared thoughts, facilitate clients own reality testing

• highly effective - 86% benefit

• brain stimulation

Medications for OCRDs

• SSRIs

• tricyclic antidepressants

Brain stimulation for OCRDs

for treatment resistant OCD (10% of people with OCD)

Trauma

life threatening/stressful life event

Trauma related disorders (TRDs)

characterized by intrusive memories, avoidance behaviors, negative mood and thinking changes, physical and emotional reactions to experiencing/witnessing traumatic event

• characteristics similar to anxiety and depression

Trauma vs trauma disorder

TRDs: avoidance, distress, impairement

Prevalence of TRDs

• PTSD: 6.8-7.8% lifetime prevalence

• more common in women

• LGBTQ experience higher rates of trauma

• 63% of black individuals experience a racially charged traumatic event

Types of TRDs

• PTSD

• adjustment disorder

• prolonged grief disorder

• reactive attachment disorder

• disinhibited social engagement disorder

• acute stress disorder

PTSD

enduring, distressing emotional disorder that follows exposure to a severe helplessness or fear inducing threat

• has to be firsthand

• re-experiencing

• avoidance

• increased vigilance

• emotional numbing and interpersonal problems

Premise of PTSD

• traumatic events shape people’s lives differently than other types of events

• cognitively: beliefs about self, world around them

• behaviorally: behaving on high alert for new danger

• emotionally: feeling fearful, depressed

• physiologically: changes in nervous system - disrupts stress response, high cortisol release

PTSD criteria

A-G criteria including experiencing a traumatic event, re-experiencing, avoidance, emotional numbing and interpersonal problems, and increased vigilance

PTSD Prevalence

• 90% of people experience trauma in lifetime

-not all trauma survivors experience PTSD

-greater intensity of trauma = higher likelihood to develop PTSD

-strong social supports = lower risk

• most common: combat and sexual assault

• 6-8% lifetime prevalence

• onset often in adolescence

PTSD Treatments

• anxiety and panic medications (SSRIs)

• prolonged/narrative exposure therapies - promote re-processing of trauma and change in maladaptive behaviors

Adjustment Disorders

• anxious/depressive reaction to life stress - moving, new job, divorce, etc

• milder than PTSD or acute stress disorder

Adjustment disorder criteria

A. The development of emotional or behavioral symptoms in response

to an identifiable stressor(s) occurring within 3 months of the onset

of the stressor(s).

B. These symptoms or behaviors are clinically significant, as evidenced

by one or both of the following:

1. Marked distress that is out of proportion to the severity or intensity of the

stressor, taking into account the external context and the cultural factors that

might influence symptom severity and presentation.

2. Significant impairment in social, occupational, or other important areas of

functioning.

Rule Outs

D. The stress-related disturbance does not meet the criteria for another

mental disorder and is not merely an exacerbation of a preexisting mental

disorder.

E. The symptoms do not represent normal bereavement and are not better

explained by prolonged grief disorder.

F. Once the stressor or its consequences have terminated, the symptoms do

not persist for more than an additional 6 months.

Prolonged grief disorder

• grief lasting longer than typically expected

• persistent/intense yearning for deceased

• pre-occupation with loss

Prolonged grief disorder criteria

A. The death, at least 12 months ago, of a person who was close to the

bereaved individual (for children and adolescents, at least 6 months

ago).

B. Since the death, the development of a persistent grief response

characterized by one or both of the following symptoms, which have

been present most days to a clinically significant degree. In addition,

the symptom(s) has occurred nearly every day for at least the last

month:

1. Intense yearning/longing for the deceased person.

2. Preoccupation with thoughts or memories of the deceased person (in children and

adolescents, preoccupation may focus on the circumstances of the death).

C. Since the death, at least three of the following symptoms have been

present most days to a clinically significant degree. In addition, the

symptoms have occurred nearly every day for at least the last month:

1. Identity disruption (e.g., feeling as though part of oneself has died) since the

death.

2. Marked sense of disbelief about the death.

3. Avoidance of reminders that the person is dead (in children and adolescents, may

be characterized by efforts to avoid reminders).

4. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death.

5. Difficulty reintegrating into one’s relationships and activities after the death (e.g.,

problems engaging with friends, pursuing interests, or planning for the future).

6. Emotional numbness (absence or marked reduction of emotional experience) as a

result of the death.

7. Feeling that life is meaningless as a result of the death.

8. Intense loneliness as a result of the death.

Rule Outs

A. The disturbance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

B. The duration and severity of the bereavement reaction clearly exceed

expected social, cultural, or religious norms for the individual’s culture and

context.

C. The symptoms are not better explained by another mental disorder

Causes of PTSD and TRDs

• generalized biological vulnerability - gene environment interaction

• psychological vulnerability

-beliefs about uncontrollability and unpredictability of situations

-behavioral/cognitive needs

• neurobiological

-elevated/restricted CRF - indicates high HPA axis activity

-hippocampus damage

• poor social support

Risk factors for PTSD

• trauma

• personality characteristics - neuroticism, antagonism

• coping deficiencies

-behavioral - withdrawal

-cognitive - negative thinking style

-biological - HPA axis dysregulation

PTSD Treatments

• imaginal or in vivo exposure

• prolonged exposure therapy - develop narrative of event, talk through in detail

• EDMR - think of traumatic event, eye movement, same thing w positive event

• medications - SSRIs - help with anxiety and panic attacks

Treatment for TRDs

CBT

• usually used for adjustment and prolonged grief disorder

• graduated/massed imaginal exposure

• narrative therapy

• challenge maladaptive beliefs