psyc 337 - PTSD and OCD

what were ptsd and ocd formerly known as?

anxiety

HiTOP classification

internalizing -> distress, fear -> PTSD, OCD

OCD in 1691

1691 sermon on religious melancholy. Parishioners obsessed by "naughty, and sometimes Blasphemous Thoughts [which]

start in their Minds, while they are exercised in the Worship of God [despite] all their endeavors to stifle and suppress them ... the

more they struggle with them, the more they increase." - John Moore, Bishop of Norwich, England

OCD traditional classification

traditionally a DSM anxiety disorder. ICD-10 (1992) created the category of neurotic, stress-related, and somatoform disorders. ocd was its own category

ocd classification in DSM-5

no longer an anxiety disorder. the sequential order of the anxiety disorders and obsessive compulsive disorder chapters in the DSM-5 reflect the close relationship among them

OCD DSM-5 Criterion A

presence of obsessions, compulsions, or both

OCD DSM-5 Criterion B

obsessions or compulsions are time consuming (ie more than one hour per day) OR cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

OCD DSM-5 Criterion C

symptoms are not attributable to the physiological effects of a substance or another medical condition

OCD DSM-5 Criterion D

the disturbance is not better explained by the symptoms of another mental disorder

for OCD specify if...

with good or fair insight, with poor insight, with absent insight. delusional beliefs. tic related - the individual has a current or past history of a tic disorder

obsessions

persistent ideas, thoughts, impulses, and images that are experienced as being intrusive and inappropriate, and cause marked anxiety or distress. ego dystonic (b/c intrusive and inappropriate). a sense of lack of control. not a natural part of the person's personality, but the person recognizes these are their thoughts. distinguished from schizophrenia or psychosis. no delusional system of thought insertion. not just worries about real life problems.

common obsessions

contamination, uncertainty, aggressive, symmetry/exactness, sexual, and somatic

people with OCD and their obsessions

people with OCD almost never act on their impulses. most patients have multiple obsessions. some developmental differences - children less likely to have sexual obsessions, more likely to have aggressive obsessions

compulsions

repetitive behaviors, sometimes thoughts. attempts to neutralize or suppress obsessions. designed to reduce anxiety from the obsession. not designed to bring pleasure or gratification. person must perform the behavior. sometimes simple actions, sometimes very bizarre and complex. frequently a form of undoing the thought or fear.

compulsive behavior example

some people engage in compulsive sexual behavior, eating, or gambling etc. these are not ocd compulsions, and are all designed for gratification

common compulsions

washing/cleaning, checking, repeating, mental

diagnosis for OCD

most people will have both obsessions and compulsion, don't need both for the diagnosis. very rare to have compulsions without obsessions. if seen, usually in children - counting, touching, ordering

how many people with OCD only have obsessions

1/4, but often these people will ritualize mentally

ocd lifetime prevalence

1.5% same in adults and children.

OCD gender ratio

slightly more common in girls/women than boys/men. in children, more common in boys

OCD age of onset

about 19, usually gradual onset

40 year follow up study of OCD natural course

first hospitalization OCD patients. at the end of 40 years, 20 percent had completely recovered. 28 percent had recovery with subclinical symptoms. 52 percent still experiencing clinically significant symptoms. of those who recovered, usually in the first 5 years of first hospitalization

cognitive models of OCD

obsessive thoughts very common. OCD = experience them as intrusive or upsetting. inflated sense of personal responsibility and self blame. if the thoughts come to pass, it's their fault. this makes them upset, increases rate of thoughts, get more upset. most ritualize to reduce anxiety. due to deficits in short term memory. people can't remember if they've checked. also very real and difficult to distinguish between real and imagined events (reality testing). can't remember if they checked, or if they thought about checking. often convinced thoughts are true

intolerance of uncertainty

Jonathan Grayson. the tendency to react negatively on an emotional, cognitive, and behavioral level to uncertain situations and events. individuals who are intolerant of uncertainty believe they lack sufficient coping or problem solving skills to effectively manage threatening situations. compulsions often attempts to increase certainty

thought/action fusion (TAF)

aka magical thinking. Moral TAF is unwanted thoughts about disturbing actions equivalent to the actions themselves. likelihood TAF is thinking about a disturbing event makes the event more probable

Neutralization

63 undergraduates with some degree of self-

reported TAF. "Keeping in mind a friend or relative who is close to you, I would like you to write out the following sentence on this piece of paper, inserting the name of the person in the blank." "I hope _____ is in a car accident." "Close your eyes and think about the situation

for a few seconds."

experimental procedure OCD study

change in anxiety OCD study

change in desire to neutralize OCD study

disgust

disgust proneness, genetic and learning influences. disgust proneness may also play a role in other disorders (spider phobics vs a cookie that a spider was on). OCD may reflect a false contamination alarm. very hard to counter-condition. can explain some of the challenges in treatment

when did PTSD first appear

1980 DSM III, roots go farther back

PTSD roots

DSM I and II stressors were seen as triggers of pre-existing diathesis. forms of dysfunction we now call PTSD were classified in other categories according to presenting symptomatology.

PTSD development

Vietnam war. high rates of disorder in soldiers, similar patterns in survivors of rape and natural disasters. departure from other DSM categories: trauma is the resumed common etiological fact. disorder is organized around it. other disorders are not organized around etiology. highly controversial

PSTD DSM-5 criteria

need exposure to a traumatic event. re-experiencing of the event in some way. avoidance (behavioral or cognitive). negative alterations of cognitions and mood. marked alterations in arousal and reactivity associate with the traumatic event. duration of the disturbance is more than 1 month

ptsd prevalence

dsm-III ptsd thought to be rare -3%. now 7-8%

ptsd gender ratio

2F:1M

trauma rates

60% men, 51% women report traumas that meet first criterion

following trauma, how many people develop PTSD

9%. women twice as likely than men, 13% vs 6%. kidnapped/tortured:54%, rape:49%

highest risk for developing PTSD

assault or violence

cross cultural PTSD studies

rates of PTSD much higher in developing non-western countries. many of these studies done following periods of turmoil and war, may be getting elevated rates. symptoms vary in different cultures

predictors of PTSD following trauma

gender - women are more likely to experience PTSD, familial psychopathology - not specific - predicts PTSD, preexisting psychopathology, internalizing symptoms in early childhood, childhood traumas/history of earlier traumas, lower IQ, nature of the trauma, social support (lack of) after trauma

nature of the ptsd trauma that impacts ptsd development

proximity, duration, level of life risk, intention, and psychological processes occurring during and after trauma. most variance in dissociation

controversy for PTSD diagnosis

what constitutes a trauma? is ptsd a normal response to an abnormal event? or an abnormal response to a normal, if stressful event? in DSM-III, event had to be outside the range of usual human experience, therefore extreme response is understandable. but, what events are outside range of normal experience? rape/murder/torture can be common.

controversies for PTSD

DSM-IV got rid of normal human experience concept, conceptual bracket creep. recent studies have looked at rates of PTSD following traumas, compared to rates of PTSD following stressful life events (not necessarily traumatic). rates of PSTD symptoms were higher after life stressors than for traumas - do you need a full blown trauma? is diathesis more important than stressor?

depression as trauma outcome

depression is as likely an outcome following a trauma as PSTD

vietnam twin studies - ptsd etiology

tested twins who were combat exposed and non combat exposed. some groups had ptsd, some not. smaller hippocampi were seen in the twins with ptsd. there is a genetic vulnerability to ptsd, smaller hippocampus changes the contextual processing of fear, predisposes you to acquire stronger emotional or hormonal responses. Pittman

ptsd and biological abnormalities

a number of biological abnormalities shown. hippocampus abnormalities, involved in explicit memory processes and encoding of context during fear conditioning. interacts critically with the amygdala during encoding of fear memories - reduced volumes, reduced neuronal integrity, reduced functional integrity

what are smaller hippocampal volumes associated with

verbal memory deficits, combat exposure severity, dissociative symptom severity, depression severity, ptsd symptom severity. evidence that hippocampal volume is heritable; smaller sizes can alter

neuroendocrine responses to stress

scars in ptsd

most of this research is cross sectional. if brain abnormalities observed in ptsd are caused by the trauma they represent a scar of the trauma. ample evidence from animal research that severe stress can damage the hippocampus. neurotic effects of cortisol; can cause atrophy and cell death of hippocampal neurons, hippocampus dense with receptors

do everyone who experience even severe acute stressors go on to develop PTSD?

no - majority do not

alternate explanations

abnormality may be an antecedent risk factor for exposure to a traumatic event that could then cause PTSD. Should then be observed in people drawn to situations associated with higher probability of trauma. Abnormality may be an antecedent vulnerability factor for developing PTSD upon exposure to a traumatic event. Should be observed prior to exposure to independent acute stressors. Abnormality may be the consequence of exposure to the traumatic event alone. Should be found in both PTSD and non-PTSD trauma survivors equally but not in unexposed persons. Abnormality may be a manifestation or product of the PTSD, that is, a PTSD sign. Should only be observed in individuals who develop PTSD, not other trauma-exposed. Abnormality may be the product of a sequel or complication of PTSD

prospective design ptsd

measure biological factor in individuals prior to traumatic event and then again afterward

twins discordant for trauma and PTSD

identify surrogates for that the trauma-exposed person would be like but for the experience of the traumatic event. non trauma exposed, identical twin. shares all the genes of exposed twin and much of the exposed twins early development environment. unique environment is non shared

Pittman study specifics

• Case-Control design

• 17 combat-exposed Vietnam veterans with PTSD (ExP+)

• 17 non-combat-exposed co-twins of ExP+ (UxP+)

• 23 combat-exposed Vietnam veterans with no PTSD (ExP-)

• 23 non-combat-exposed co-twins of ExP- (UxP-)

• All male; in their early 50s

• Examined hippocampal volumes in each of the four group

pitman study conclusions

Smaller hippocampal volumes in trauma-exposed individuals diagnosed with severe, unremitting PTSD (consistent with previous research). Non-combat-exposed co-twins show comparable hippocampal volumes. Suggest smaller hippocampi in PTSD represent a pre-existing, familial vulnerability, not the result of neurotoxic event(s). Combat-exposed vets showed higher rates of major depression, and more severe alcohol

histories. BUT combat unexposed twin brothers did not

effect of reduced hippocampal volume

Hippocampal morphology implicated in conditioning and extinction

of fear responses in animals, may be involved in the contextual

processing of fear

• Rodents with hippocampal lesions show stronger conditioned fear

• Smaller hippocampal volumes also associated with diminished

neuroendocrine regulation of the HPA axis

• Smaller inherited hippocampal volumes may therefore predispose

individuals to:

• acquire stronger and/or more persistent conditioned emotional responses

• OR stronger hormonal stress responses

• Or BOTH

• When exposed to a traumatic event

methodological issue

research on PTSD is often done on people with a vested financial interest in being diagnosed. questioning of credibility.

other controversies of ptsd

close relationship between ptsd and depression. comorbid. predict each other. similar characteristics (greater prevalence, over generalized autobiographical memories, smaller hippocampal volume, increased amygdala reactivity , risk of developing depression is just as high after a trauma as PSTD