Trauma and Stressor Related Disorders + OCD and Related Disorders

>, any, alcohol, 3, recover

PTSD: Background

-Reclassified from an anxiety disorder to a trauma and stressor-related disorder

-Prevalence = 3.5%; Female _ male 2:1

-Can occur at ___ age

-Increased lifetime prevalence of _______ or drug abuse

-Symptoms usually occur within first _ months after trauma

-~50% completely _______ in 3 months

exposure, death, experiencing, witnessing, after, memories, flashbacks

PTSD: Diagnosing, pt 1

-________ to actual or threatened _____, serious injury, or sexual violence in 1+ of the following ways:

• (1) Directly ___________ the traumatic event

• (2) _________, in person, the event as it occurred to others

• (3) Learning that the traumatic event occurred to a close family member or close friend 

• (4) _____________ repeated or extreme exposure to aversive details of the traumatic event 

-Presence of 1+ of the following symptoms beginning _____ the event occurred:

• (1) Recurrent, involuntary, intrusive distressing ________ of the event

• (2) Recurrent distressing dreams 

• (3) Dissociative reactions (___________)

• (4) Distress with exposure to internal or external cues that symbolize/resemble the event

• (5) Marked physiological reactions to internal/external cues 

avoidance, external, negative, remember, negative, interest, positive, arousal, startle, sleep, 1

PTSD: Diagnosis, pt 2 

-Persistent ___________ of stimuli associated with the event

• Avoidance of or efforts to avoid distressing memories, thoughts, feelings 

• Avoid _________ reminders (people, places, conversations, objects) 

-_________ alterations in cognition or mood 

• Inability to _________ important aspects (dissociative amnesia) 

• Persistent/exaggerated ________ beliefs or expectations about oneself, others, the world 

• Persistent negative emotional state

• Diminished ________ or participation in significant activities 

• Detachment or estrangement feelings to others

• Inability to experience _________ emotions 

-Marked alterations in _______ and reactivity associated with the event, 2+ of the following: 

• Irritable behavior and angry outburst 

• Reckless or self-destructive behavior

• Hypervigilance 

• Exaggerated _______ response 

• Problems with concentration

• _____ disturbance

-Duration > _ month

detached, outside, body, unreality

Additional Specifiers to Diagnosis: PTSD w/ Dissociative Symptoms

-Depersonalization → feeling ________ from/feeling like an _______ observer or one’s mental process or body (like a dream)

-Derealization → experiences of ________ of surroundings, feeling like the world around you is unreal/dreamlike/distant/distorted

psychotherapy, SSRI, benzodiazepines

PTSD: Treatment

-____________ (ASAP)

• Cognitive processing therapy, eye movement desensitization and restructuring and prolonged exposure therapy

-____ → Sertraline, citalopram, paroxetine

• Helpful with depression, panic attacks, sleep issues, startle response

• Beta blockers can help with anxious arousal, as does clonidine

• ____________ are generally contraindicated

PTSD

What is the leading diagnosis in this patient?

A 29 y/o man presents to the clinic with insomnia, nightmares, and difficulty concentrating for the past 3 months. He reports frequent flashbacks of a car accident in which his close friend was killed. 

He avoids driving and refuses to talk about the event, saying it “feels like it’s happening all over again” when he does. He also feels on edge, becomes startled by loud noises, and says he’s been angry and irritable with his family. His wife notes that he has become emotionally withdrawn and no longer enjoys activities like he used to. 

He denies substance use or other medical issues. 

immediately, 3, 1

Acute Stress Disorder

-Same diagnostic criteria as PTSD except: symptoms develop ____________ after traumatic event and persist for _ days - _ month

Acute Stress Disorder

What is the leading diagnosis in this patient?

A 26 y/o woman comes to the ED 10 days after surviving a home invasion and assault. She reports having recurrent nightmares and intrusive memories of the attack. She becomes panicky whenever she hears footsteps behind her and avoids leaving her apartment.

She says she feels “numb and detached”, has trouble sleeping, and is easily startled by sudden noises. She keeps replaying the event in her mind but tries to block out the details.

No prior psychiatric history and denies substance use.

stressor, 3, relationship, death, exceeds, societal, normal, 6

Adjustment Disorder

-Development of emotional or behavioral symptoms in response to an identifiable ________ occurring within _ months 

• Ending of a __________, business difficulties, marital problems, natural disaster, _____ of a loved one, leaving home, coming back home, marriage, and becoming a parent 

-Intensity, quality, or persistence of response _______ the normal expectation for cultural, religious, age-appropriate, ________ norms 

-Symptoms do not represent _______ bereavement 

-Symptoms do not persist for > _ months 

Adjustment disorder

What is the leading diagnosis for this patient?

A 30 y/o man comes to his PCP because he has been feeling sad, anxious, and unmotivated for the past 6 weeks. He says these symptoms began shortly after he was laid off from his job.

He has been arguing with his partner, sleeping poorly, and feels “on edge”. He reports difficulty concentrating while applying for new positions but denies hopelessness, suicidal thoughts, or loss of interest in all activities.

He has no history of psychiatric illness, and his symptoms do not meet criteria for MDD or GAD

thoughts, repetitive, unwanted, >, childhood, both, time-consuming, distress, insight

OCD: Background

-OCD has been reclassified from an anxiety disorder to its own category

-Obsessions → recurring distressing _______

-Compulsions → _______ actions

-Usually recognized by the individual as ________/unwarranted

-Female _ male (adulthood); male > female (_________)

-Presence of obsessions, compulsions, or ____. The obsessions or compulsions are ____-_________ or cause significant _________ and impair functioning

-Specify level of ______ or presence of tics

chronic, psychotherapy, Fluoxetine

OCD: Treatment

-Typically _______ if left untreated

-Treatment

• _____________

• Pharmacotherapy → SSRIs (_________), need typically a higher dose and longer response time than depression 

OCD

What is the leading diagnosis in this patient?

A 24 y/o woman presents to the psychiatry clinic because she spends hours each day cleaning her apartment and washing her hands repeatedly. She reports persistent, intrusive thoughts that her apartment is contaminated with germs.

She tries to resist these thoughts but feels intense anxiety until she performs rituals such as scrubbing surfaces or handwashing. She recognizes that these thoughts are excessive and unreasonable, but feels unable to control them. Her routines interfere with her work, social life, and sleep.

She has no history of psychosis, mania, or substance use

defects, physical, minimal, mirror, mental

Body Dysmorphic Disorder

-Preoccupation with 1+ perceived ______ or flaws in ________ appearance that are not observable or appear _________ to others

-Repetitive behaviors like ______ checking, excessive grooming, skin picking, reassurance seeking

-_____ acts like comparing appearance to others

Body dysmorphic disorder

What is the leading diagnosis in this patient?

A 21 y/o man presents to the clinic because he spends several hours a day examining his face in the mirror. He believes his nose is severely crooked, though others say it appears normal.

He has attempted multiple cosmetic procedures and uses heavy makeup to correct perceived flaws. He avoids social interactions, feeling embarrassed and anxious about how others perceive his appearance. His preoccupation interferes with his college classes and part-time job.

He denies psychosis, substance use, or suicidal thoughts, although he admits feeling distressed and hopeless about his appearance.

discarding, possessions, save, discarding, distress, trait

Hoarding Disorder

-Persistent difficulty __________ or parting with ___________ regardless of actual value 

-Perceived need to ____ items and distress when ___________ them

-Causes significant ________ and impairment of functioning 

-80 to 90% have excessive acquisition _____

Hoarding disorder

What is the leading diagnosis in this patient?

A 45 y/o man is brought to the clinic by his adult daughter because his house is cluttered with stacks of magazines, newspapers, and random items, making it difficult to move around safely.

He reports that he cannot discard items, even those that seem worthless to others, because he feels an intense distress at the thought of throwing them away. He keeps things thinking they might be useful “someday”.

He denies symptoms of depression or psychosis and has no history of OCD treatment, though he admits that his hoarding behavior has been progressively worsening over the past 20 years. He lives alone and has social isolation because friends and family avoid visiting due to clutter.

pulling, hair, anxiety, any, rituals

Trichotillomania

-Recurrent ________ out of one’s hair, leading to ____ loss

-May be triggered by ________ or boredom; may be pleasurable

-Repeated attempts to decrease or stop activity

-Can occur at ___ body region → MC are scalp, eyebrows, eyelashes

-May involve _______

-Can lead to the development of Bezoars and fecal impaction

Trichotillomania

What is the most likely diagnosis?

A 17 y/o girl is brought to the clinic by her mother because she has patchy hair loss on her scalp. The mother reports that the hair loss is not due to lice or infection.

The patient admits that she pulls out her hair when stressed or anxious, particularly when studying for exams. She feels tension before pulling and relief afterward. She tries to hide the patches with hats or scarves and has been embarrassed to attend social events. 

She has no history of dermatologic disease or eating disorder. 

picking, lesions, face

Excoriation Disorder

-Recurrent skin _______ → skin ______

-Repeated attempts to decrease or stop

-MC: ____, arms, hands 

Excoriation Disorder

What is the most likely diagnosis?

A 25 y/o woman presents to dermatology because of chronic lesions on her arms and face. She reports repeatedly picking at her skin, particularly during times of stress or boredom, leaving scabs and scars.

She recognizes that the behavior is harmful and excessive, but feels an urge she cannot resist, followed by relief after picking. She avoids social activities because she is self-conscious about the marks.

No history of dermatologic disease explains the lesions.