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

DSM-IV-TR vs DSM-5

in DSM-IV-TR, Obsessive-Compulsive and Related Disorders and Trauma-
Related Disorders were included with Anxiety Disorders -some common symptoms, risk factors, and treatments with anxiety disorders and in DSM-5 created new chapters for Obsessive-Compulsive and Related Disorders and Trauma-Related Disorders

obsessive compulsive and related disorders

obsessive compulsive disorder, body dysmorphic disorder, hoarding disorder

DSM 5 Criteria: OCD

obsessions and/or compulsions - the obsessions or compulsions are time consuming (e.g. require at least 1 hour per day) or cause clinically significant distress or impairment

obsessions

intrusive, persistent, unwanted, and uncontrollable thoughts or urges, or images -experienced as irrational, interfere with normal activities, most common: contamination, sexual and aggressive impulses, body problems, symmetry or order

incidence of obsessions

contamination: 32.9%, aggression: 16.6%, need for exactness: 8.5%, religious: 6.3%, somatic: 6.2%, sexual: 5.3%, hoarding/saving: 4.0%, miscellaneous: 20.2%

compulsions

repetitive behaviors or mental acts (or rituals) a person feels compelled to perform
to avoid distress, extremely difficult to resist the impulse, may involve elaborate behavioral rituals, 78% viewed compulsions as “silly or absurd”, yet still unable to stop them, compulsive gambling, eating, etc. NOT considered compulsions, since pleasurable

OCD compulsions

cleanliness and orderliness -elaborate rituals, repetitive, magically protective acts - e.g., counting or touching a body part, repetitive checking - returning multiple times to ensure
stove/faucets/lights are turned off, windows fastened, doors locked

incidence of compulsions

checking: 28.1%, cleaning/Washing: 25.9%, mental: 11.5%, repeating: 11.0%, ordering/arranging: 5.3%, hoarding/collecting: 3.2%, counting: 2.6%, miscellaneous: 12.4%

OCD develops

either before age 10 or during later adolescence/early adulthood, gender as a risk factor - childhood OCD

OCD often chronic

only 20% complete recovery, 76% have comorbid anxiety disorder, 63% have depressive or bipolar disorder, 33% have hoarding symptoms, substance abuse is common

body dysmorphic disorder

preoccupied with an imagined or exaggerated defect in appearance -perceive themselves to be ugly or “monstrous” and engage in compulsive behaviors - check their appearance in mirrors often and camouflage their appearance (tanning, makeup, plastic surgery)

DSM - 5 criteria body dysmorphic disorder

preoccupation with a perceived defect or markedly excessive concern over a slight defect in appearance, others find the perceived defect(s) as 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 fat

body dysmorphic disorder

high levels of shame, anxiety, and depression - symptoms are distressing, avoid contact with others, fear of judgment, 40% are unable to work, occurs only slightly more often in women, rare disorder, prevalence in women less than 2%, nearly all have another comorbid disorder: depression, social anxiety disorder, OCD, substance use disorders, symptoms of BDD are similar across cultures, yet, the body part that becomes focus of concern may differ by culture

hoarding disorder

new diagnosis for DSM-5, cannot part with acquired objects, most objects are worthless, extremely attached to objects, resistant to relinquishing object, 2/3 are unaware of severity of problem, 89-90% excessive buying, 33% engage in animal hoarding, animals often receive inadequate care, severe consequences squalid living conditions

DSM-5 criteria: hoarding disorder

persistent difficulty 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 of the home or workplace to the extent that their intended use is compromised unless others intervene

what is known about hoarding disorder

nearly 2-3% of the general population engaged in hoarding behaviors, more frequent in older than younger age groups, more common in men than women, people who engaged in hoarding behaviors (vs. OCD) also tended to experience: alcohol dependence, paranoid, schizotypal, avoidant, and obsessive–compulsive personality disorder traits, excessive physical discipline before 16 years of age, parental psychopathology, the psychological distress of individuals dealing with hoarding behaviors is quite evident

lifetime prevalence

2% OCD (slightly more common in women), 2% BDD (slightly more common
in women), 1.5% Hoarding disorder (no gender differences)

comorbidity

high rates of comorbidity among all three syndromes, also comorbid with depression
and anxiety, OCD and BDD often comorbid with substance use disorders

posttraumatic stress disorder

extreme response to severe stressor: recurrent memories of the trauma (intrusion), avoidance of stimuli associated with trauma, negative emotions/thoughts, increased arousal, emotional numbing and exposure to a traumatic event that involves actual or threatened death, serious injury, or sexual violation e.g., war, rape, natural disaster: direct exposure, witnessing the trauma in person, learning that a relative or close friend was exposed to a trauma indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

PTSD

trauma leads to intense fear or helplessness, symptoms present for more than a month, women and PTSD - rape most common type of trauma (Creamer
et al., 2001)

four categories of symptoms for PTSD

1. intrusively re-experiencing the traumatic event

2. avoidance of stimuli

3. other signs of mood and cognitive changes

4. increased arousal and reactivity

intrusively re-experiencing the traumatic event

recurrent, intrusive memories, nightmares, intrusive thoughts, or images, dissociative reactions (flashbacks), intense reactivity

avoidance of stimuli

e.g., refuse to walk on street where assault occurred, internal or external reminders

other signs of mood and cognitive changes

inability to recall key features of the trauma, negative beliefs/expectation (thoughts and emotions), self-blame/ blaming others, withdrawal, feeling of detachment or estrangement from others, inability to experience positive emotions

increased arousal and reactivity

irritability, aggressiveness, recklessness or self-destructiveness, insomnia, difficulty concentrating, hypervigilance, exaggerated startle response - tends to be chronic, higher risk of suicide and self injuries, illness

acute stress disorder

symptoms similar to PTSD, duration shorter, symptoms occur between 3 days and 1 month after trauma, as many as 90% of rape victims experience ASD, ASD predicts higher risk of PTSD within 2 years - two major concerns about ASD diagnosis

genetic and neurobiological factors

heritability (OCD, BDD, and hoarding) - 40-50%, hyperactive regions of the brain when
shown objects that provoke symptoms - (e.g., soiled glove), orbitofrontal cortex, caudate nucleus, anterior cingulate

etiology of OCD behavioral

operant conditioning, compulsions negatively reinforced by the reduction of anxiety, (more resistant to extinction)

etiology of OCD cognitive behaviors

lack of a satiety signal, Yedasentience - subjective feeling of knowing/completion, knowing that you have thought enough or cleaned enough, individuals with OCD have a yedasentience deficit, fail to gain an internal sense of completion, attempts at thought suppression - trying to suppress thoughts may make matters worse

etiology of BDD - behavioral and cognitive factors

focus on details of appearance: no actual distortion of physical features, attend to physical attractiveness/features, e.g., facial symmetry, miss the gestalt, or the whole picture, become engrossed in small flaws, believe in an exaggerated importance of appearance, avoid situations in which their appearance might be judged

etiology of hoarding disorder

evolutionary perspective: adaptive to stockpile vital resources, cognitive-behavioral factors: poor cognitive organizational abilities, problems with attention, slow, and generate more categories – highly anxiety provoking, difficulty making decisions unusual beliefs about possessions: comforted by objects (emotional attachment), frightened of losing them, core of sense of identity, sense of responsibility (feel a sense of grief when part with objects), avoidance behaviors

etiology of PTSD common risk factors with other anxiety disorders

genetic, overactive amygdala, childhood exposure to trauma, selective attention, neuroticism, negative affectivity, two-factor model of conditioning also applicable

etiology of PTSD unique factors

severity and type of trauma, neurobiological: smaller hippocampal volume linked to PTSD, difficulty organizing memories and placing the context (safety
cue), avoidance coping, dissociation (may keep from confronting
memories of trauma), memory suppression: dissociation - feeling removed from one’s body or emotions/unable to recall important aspects of the trauma), social support, and ability to grow from the experience enhance coping - help make sense of traumatic
events

treatment of OCD and related disorders

medications - SSRIs (Serotonin reuptake inhibitors), Tricyclic antidepressants: Anafranil (clomipramine), exposure plus response prevention: not performing the ritual exposes the person to the full force of the anxiety provoked by the stimulus (violates expected outcomes/assumptions), the exposure results in the extinction of the conditioned response (the anxiety), cognitive therapy: challenge beliefs about anticipated consequences of not engaging in compulsions, usually also involves exposure (violates expected outcomes/assumptions)

treatment of PTSD

medications (SSRIs): relapse common if medication is stopped, exposure to memories and reminders of the original trauma: either direct (in vivo) or imaginal, virtual reality (VR) effective, to extinguish the fear response- particularly the over-generalized fear response, to help challenge the idea that the person could not cope with the anxiety and fear generated by those stimuli – avoidance reduced, more effective than medication or supportive therapy, treatment can be difficult at first - possible increase in symptomatology, cognitive strategies: enhance beliefs about coping abilities, cognitive processing therapy (some elements of exposure) – reduce guilt and dissociation, treatment (exposure therapy) of ASD may prevent PTSD, shows benefits even 5 years after the traumatic event