PSYCH 257 - Chapter 6 (Preoccupation + Obsession)

somatic symptom disorder clinical description

a. 1+ somatic symptoms that are distressing or result in significant disruption of daily life

SOMATIC SYMPTOMS ARE PHYSICAL SYMPTOMS THAT A PERSON FEELS IN THEIR BODY (pain, fatigue, shortness of breath, gastrointestinal issues…)

b. excessive thoughts, feelings, or bheaviours related to somatic symptoms manifested by 1+ of following:

1. disproportionate and persistent thoguhts about the seriousness of one’s symptoms

2. persistently high anxiety about health

3. excessive time + energy devoted to tehm

c. total state of being symptomatic is PERISTENT - 6+

specifiers: with predominant pain, persistent (6+ months, severe symptoms, marked impairmnet), severity (mild (1 in B) , moderate (2+ in B) severe (2+ in B, plus multiple somatic complaints or one very severe

REMEMBER!!! their somatic symptoms do not increase in intensity bcz of their anxiety!!!!!! they just have impaired daily functioning + distress because of the somatic symptom tehy have!! they believe its more serious than it is and they freak out about it.

somatic symptom disorder vs illness anxiety disorder

SSD —> strong worry about the seriouness about their EXISTING somatic symptom (ex. this headache never goes away!! i can’t focus on anything, its causing me severe distress + impairment. i cant stop thinking about it)

IAD: “this little rash might be skin cancer, my stomach’s upset is it stomach cancer?? my throat!! is it throat cancer??”

• anxiety over getting an illness, any illness.

difference between somatic symptom disorder + functional neurological disorder?

SSD:

• general physical sumptoms vs neurological symptoms

• excessive thoughts, feelings, or ehaviours about symptoms + distress about health vs loss of motor/sensory function

• symptoms persist for 6+ months, vs sudden or chronic

• often linked to psychologcical factors but not always evident vs may follow psychological stressors but can also occur without identifiable triggers

• vague and varied symptoms vs specific to neurological function

• heightened anxiety + preoccupation with health vs

functional neruological disorder

• neurological symptoms (seizures, tremors, paralysis)

• loss or alteration of motor function, symptoms resemble neurological conditons

• symptoms can be sudden or chornic, while SSD is persistent (6+ months)

• symptoms may follow psychological stressors but can also occur without identifiable triggers

• specific to neurological function

SSD is characterized by a heightened focus on and distress about physical symptoms. may experience pain as more intense or pervasive due to excessive worry and emotional response to symptoms

FND is not amplificaiton! its more a disruption of normal neurological function due to lots of stress. new neurological symptoms not necessarily related to prior pain conditions.

SSD example:

• chronic pain (severe persistent pain (6+ months)) without clear medical cause, freuqently worry its a serious health problem

FND

• seizures, without electrical activity in the brain seen in seizures, triggered by stress

• abnormal gait (unsteady gait, drag a leg, but no actual physical reasons for this)

BUT ITS REAL PHYSICAL PAIN IN BOTH CONDITIONS, WITH REAL EFFECTS ON DAILY LIFE + FUNCTIONING!!!!!!

illness anxiety disorder (hypochondriasis)

• concern is primarily with the idea of being sick instead of the physical symptom itself

a: preoccupation with having a serious illness

b: somatic sypmtoms dont exist, or only exist very mildly and is DISPROPORTIONATE to the risk

c: high level of health anxiety

d: excessive health-related behaviours (ex. repeated checking) or maladaptive avoidance of hospitals, for fear theyll find something

e: 6+ MONTHS!! PERSISTENT!! specific illness may change, but the whole thing is 6+ months

f: not better explained by another mental disorder

specifiers: care-seeking type or care-avoidant type

integrative model of causes of somatic sypmtom + illness anxiety disorders

first, we have a trigger (information, event, illness, image) which leads to a perceived threat, which leads to apprehension. the apprehension manifests into increased focus on body, increased physiological arousal, and checking behaviours and reassurance seeking. all of these behaviours lead into a preoccupation with perceived abnormalities of bodily sensations and states, which are misinterpreted as indicating of severe ilness, which is a perceived threat again, and the cycle reperats.

potential biological + psychological vulnerabilities for somatic symptom disorders

• run in families! genetic contributions

• tendency to overrespond to stress, so its a nonspecific genetic contribution

• psychological: tendency to view negative life events as unpredictable and unctrollable

• can even be learned from family members who focus anxiety on specific physical conditions and illness.

3 factors that may contribute to causing somatic symptom disorder?

1. can develop in the context of a stressful life event (ex. death, illness)

2. ppl who develop them tend to have disproportionate incidence of disease in their family when they were children (may not develop then, but may develop as adults cause they carry strong memories of the illness)

3. social + interpersonal influence

   1. secondary gain (positive conseuqences of being sick (ppl looking after you, being more gentle on you))

   2. taking on a sick role (being cared for, getting increased attention for being ill)

treatments for somatic symptom disorder

1. CBT to target dysfunctional stress coping, attentional processes, cogniton, behaviours related to somatic symptoms

   1. ex. relaxation techniques, coping strategies, less hypervigilance, “this ehadache must be a brain tumour”, “its prolly not a brain tumour, headaches are common! they do not indicate a severe illness”

2. antidepressants (Paxil - SSRI)

3. buuut CBT on top.

4. goal is to reduce help-seeking behaviours

functional neurological symptom disorder (conversion disorder)

• anxiety converted into physical symptoms to find expression

• neurological dysfunction (paralysis, blindness, difficulty aphonia) WITHOUT physical pathology to explain it

• DISSOCIATIVE SYMPTOMS

clinical description of functional neurological symptom disorder

a. one or more symptoms of altered voluntary motor or sensory function

b. clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions (ex. seizures without comparable electrical activity)

c. symptom is not better explaiend by another mental or medical disorder

d. distress + impairment

specifiers: acute episode (less than 6 months (woke up paralyzed, persistent (6+)

• think about the girl who woke up paralyzed and her voice din’t owrk for a while

specify if

• with psychological stressor or without psychological stressor

• can occur without a specific psychological stressor! can be a combination of things

malingering

FAKING. motivation is money, to avoid work, to get drugs, or to avoid being convicted. they are AWARE they are faking

FOR EXTERNAL GAIN

factitious disorders (munchausen syndrome)

• somewhere btw malingering and functional neurological symptom disorders

• theyre faking it for attention!!!!!! for the sick role!!!!!!!

• malingering’s motivation is finaical gain, avoiding work or drugs, and they are completely aware theyre faking or exaggerating symptoms

they are aware theyre faking it, but they dont konw why they feel compelled to do so

imposed on self: induces illness in thmemselves

imposed on another: a person (mother) falsifies or induces illnessin someone else

ex. mixing feces into child’s vomit

ex. injecting urine into child’s intravenous line

FOR INTERNAL PSYCHOLOGICAL NEED

clinical description of factitious disorder

a. falsification of physical or psychological signs of symptoms (PHYSICAL OR PSYCHOLOGICAL)

b. presents himself to be ill, impaird or injured

c. the deceptive behaviour is evident even in teh basence of obvious external awards (ex. money)

d: not better accunt by another mental disorder

specifiers: single episode, recurrent episodes (2+ events of falsificaiton)

psychological factors affecting medical condition

• a somatic symptom disorder

• presence of a diagnosed medical condition (asthma, diabetes, severe pain with a known medical condition) that is INCREASED IN FREQUENCY OR SEVERITY BY PSYCHOLOGICAL OR BEHAVIOURAL FACTORS

  • ex. high levels of anxiety worsening existing condition of asthma

• another example: patient with prexisting diabetes, in denial about the need to regualrly check it (but you do have to), and this is neglect, which is a behavioural/psychological factor affecting the medical conditon (making it worse)

causes of functional neurological symptom disorder

freud:

1. unacceptable, unconscious conflict

2. repressed conflict

3. anxiety increases, converted into physical symptoms, relieving pressure to have to deal directly with the conflict

4. increased attention and sympathy from loved ones: secondary gain

la belle indifference

indivudlas dont seem stressed about their symtpoms

treatments of functional neurological disorder

1. identify the trumatic or stressful life event

   1. rexperiencing can lead to catharsis

2. reduce any reinforcing consequences (secondary gains of money, attention…)

   1. encouragement to do better, and less people speaking for you and doing things for you

3. cognitive-behavoural programs

   1. hypnosis doesn’t do shit but CBT does help

obsessive-compulsive disorder (OCD)

• severe generalized anxiety

• recurrent panic attacks

• debilitating avoidance

• major depression

• enslaved by ritual

treatments for illness anxiety disorder

• explanatory therapy (clinician went over the source + origins of the symptoms) to try to put their mind at ease, but this only really helps with milder forms when theyre “less far gone”

• CBT: focused on identifying and challenging illness-related misinterpretations of physical sensations and even showing patients how to cause weird sensations in their body so them knowing they can create them makes it feel like they do have some control.

• exposure therapy on documentaries about diseases without seeking reassurance or checking for symtpoms helped reduce anxiety

disease conviction

• the difficult-to-shake belief that they do have a disease

• back in doctors office, sure that the doctor missed something

• feature of illness anxiety disorder

obsessions

• intrusive, nonsensical thoughts, images or urges indivudal tries to resist

• ex. “what if i accidentally hurt someone? i know i locked the door, but what if i didn’t actually do it, i need to check”

compulsions

thoughts + actions to suppress obsessiona dn provide relief

ex. handwashing, or thinking about certain words in a speicifc order

diagnostic criteria for OCD

a. presence of obsessions, compulsions or both

obsessions:

1. recurrent + persistent thoguhts, urges, images that are are unwanted, cause distress

2. tries to ignore them

ocmpulsions

1. repeative behaviours or mental acts that the indivudal feels the need to do in resposne to an obsesion

2. aim to reduce distress

b: time consuming, cause distress or impairment

c: cant be attibute dot drugs or other medical conditon

d: not better explained by another mental disorder

specifiers:

• insight (good, poor, absent/delusions)

• tic-related (currentn or past history of a tic disorder)

symmetry ocd

• have to do things juuuust right, cant stop untilyou get it just right

• putting things in specific orders, repeating rituals

forbidden thoughts or actiosn (aggressive, sexual, religion)

fears of harming self or others

fears of offending god

checking, avoidance, repeated requrests for reassurance

clenaing ocd

• fear of germs or contaminants

• repretive or excessive washing, using glvoes masks to do daily tasks

hoarding ocd

• fera of throwing anything away

• collecting/saving objects iwth little to no actual or sentimental value

• ex. hoarding food wrappings (not for an art project lol)

CAN OCD BE ILLOGICAL??

YES ABSOLUTELY. YOU MAY EVEN BE COMPLETELY AWARE THIS IS IRRATIONAL, BUT YOU CANT STOP.

tic disorder + ocd

somehow theyre comorbid!

often related to symmetry

pediatric autoimmune neuropsychiatric syndrome (PANS)

occurs after strep throat

this OCD is more likely to be male, dramticonsent of symtoms, fever, sore throat, full remissions between episodes, remission of symtpoms during antibiotic therapy, past strep throat infections, clumsiness

types of obsessions + intrusive thoughts

1. harming

   1. jump in front of a car

2. contamination

   1. caught e coli from the washroom

3. inappropriate or unacceptable behaviour

   1. swearing at boss

   2. hoping someone doesnt succeed

   3. taboo sexual acts

4. doubts about safety, memory, so on (false memory ocd)

   1. did i lock the door, did i leave the stove on? did i leave the car unlocked? I KNOW I LOCKED IT THO.

causes of OCD

generalized psychological vulnerability + generalied boilogical vulnerabiltiy back up stress from life evnts, which lead to intrusive thoughts, images or impulses, which lead to teh specific psychological vulnerability that thoughts are dangeorus and unaceptable, which creates an anxious apprehension focused on recurring thoughts, which leads to cognitive or behavioural rituals to neutralize or suppress thoguhts, but also SPV can lead to false alarms cause of stress break out, which can lead to learned alarms, which also feed into anxious apprehenison, and cognitive or behaviourlal rituals to neutralize thoughts can lead straight to OCD but obviously fueld by anxious apprehension.

treatments of OCD

1. psychological treatments over drugs!!

2. SYSTEMATIC EXPOSURE TO HARMLESS OBJECTS OR SITUATOINS

   1. ocd video: just make the sandwich on the counter without cleaning anything, contamination ocd

   2. the goal is to see them do it, see theres no bad consequences on an emotional level

3. combined effects of medicaiton + psychological treatments?

   1. ERP (exposure + response prevention) + clomipramine

      1. did nothing!!

so ERP on top!!

SSRIs helpsometimes, but theyre only for symtpom management, so its better to do ERP and existing SSRI than ERP and clomipramine.

psychosurgery (what is it? and how is it used in OCD?)

surgical lesions to the brain if you cant respond to either drug or psychological treatment

OCD: cingulate bundle (cingulotomy), and capsulotomy

deep brain stimulation

• BETTER THAN PSYCHOSURGERY CAUSE ITS REVERSIBLE

• electrodes are placed through small holes DRILLED IN THE SKULL (so it is an invasive procedure), and connected to a pacemaker-like device in the brain

concept check 6.2

1. obsessions

2. compulsions

3. ERP

what is ERP

• form of CBT used for OCD, but also anxiety, phobias, and eating disorders

• indivudals are exposed to distressing stimuli

• learn therapuetic techniques to prevent their usual maladpative response

• they just get used to experiencing hte distress BUT NOT GIVING IN TO THE COMPULSION (response-prevention component)

what is reality testing in OCD

clinicans work with ppl to help them recognize difference between intrusive thoughts and whats actually real and logical through CBT and exposure

body dysmorphic disorder (BDD)

• more similar to OCD bcz of obsession than somatic symptom disorder

• people with BDD complain of persistent, intrusive, and horrible thoughts about their appearance (obsessions)

• compulsions of checking mirrors to check appearance

what dsiorders are comorbid with BDD?

• OCD!

• found in family members

• compulsive behaviours like repeatedly looking in mirrors to check physical features

• approx same age of onsent, same course

• AND SOCIAL ANXIETY DISORDER

ideas of reference

they think everything that goes on in their world is somehow related to them, their imagined defect

• ex. if someone’s zoned out and staring at them, they think theyre staring at their perceived flaws

• ex. if someone just turned thier head, looked and turned back they would think that neutral interaction means that person finds them unattractive or strange

• they may beleive media messages that have nothing to do with them are mocking at their own appearance issues

diagnostic criteria for BDD

a. preoccupation with 1+ perceived dfects or falws (that are slight or not observable to others)

b. repetivie behaviours or mental acts in response (ex. mirror checking, pulling at skin, seeking reassurance or comparing appearance to others)

c. distress

d. not better explained by EATING DISORDER!!!

specifiers: muscle dysmorphia (not muscular enough), and isnight (good, poor, delusional)

• good insight (prolly not true but can’t stop thinking it)

• poor insight (beliefs are prolly true)

• absent insight/delusional beliefs (convinced bdd beliefs are ture entirely)

high comorbiity with eating disorders for women

age of onset: early adolescne through the 20s, peaking at the age of 16-17

CHRONIC.

causes of BDD

• dont know if its biological

• similar to ocd, so similar etiology maybe is a lead

treatments of bpd

1. clomipramine, fluvoxamine (block reuptake of serotonin, but not SSRIs), surprisngly effective for bdd, and also for ocd

2. ERP also good for BDD and OCD

people get plastic surgery to help! but distress + severity actually increase after surgery, not decrease!! possibly cause its increased attention to themselves

what are the 3 major characteristics of hoarding disorder (+ def)

1. excessive acquisition of things

2. difficulty discarding anything

3. living with excessive clutter under conditions best characterized as gross disorganization

fearing if they grow away things, they might urgently need it

underlying behaioural characteristics of this disorder

1. maladaptive cognitions

   1. “if i throw it away, ill lose an important part of my memories”

   2. “i might find hte perfect use for it right after i lose it”

2. dysfunctional attachments to people and possessions

   1. “this chair looks lonely, i have to keep it”

   2. “ive had these books for so long, i have to keetp them, its rude to throw them away”

   3. “nooo this reminds me of that time i tried to take up knitting its important”

purpose of hoarding disiorder

• great pleasure, euphoria (age of onset teenage years)

• think retail therapy, do it when ur upset

what disorders is hoarding disorder comorbid with?

• OCD again

• in fact, insight is specified

• age of treament is 50 years after yeras of hoarding and someone bringsthem in

• OCD waxes and wanes (episodes), hoarding behaviour can begin early and get worse with each decade

• EVEN CONSIDERED A SUBTYPE OF OCD

• WHY?? think distressing thoughts about discarding items, and thoughts about keeping them

types of hoarding

• object hoarding

• animal hoarding

  • animals in freezers, dead, on the floor, cant take care of them, can’t get rid of them

• paper hoarding

• food hoarding

• garbage/trash hoarding

• sentimental hoarding

treatments for hoarding disorder

• CBT

• assign different values to objects, reduce anxiety by throwing away items that are less valued

• results less modest than when used with OCD

• little known interventions for those who hoard animals

trichotillomania

urge to pull out one’s own HAIRRRRRRRRR.

DO NOT GENERALIZE TO OTHER THINGS

ITS ONLY HAIR!!!!

trichotillomania —> thrix (hair) + tillein (to pull) + mania (madness)

excoriation disorder

skin-picking disorder. repetive, compulsive, tissue damage

impulse-control disorder —> OCD is not an impulsive c

BDD —> pick skin to improve appearance, skin-picking is more impulsive

what is habit reversal training

patients are taught to be more aware of their repetititve behaviour as its about to beign, then sub a different behaviour in

ex. instead of picking, put lotion on skin

associating soemthing idfferent with the habit helps! with impulse control disorders!

drug treatments for trichotillomania + excoriation disorder

• SSRIs, promise for trichotillomania, not so much for excoriation.