clinical and mental illness
Psychological Assessment
Concerned with the bodily changes that accompany psychological events or that are associated with a person’s psychological characteristics.
Measures such as heart rate, tension in the muscles, blood flow in various parts of the body, and brain waves to study the psychological changes that occur when people are afraid, depressed, asleep, imagining, solving problems, and so on.
The assessments described here are not sensitive enough to be used for diagnosis; they can, however, provide important information
Examples of psychophysiological test instruments are: electrocardiogram, electrodermal responding, and EEG
Diagnosis of Mental Disorders
Diagnosis:
The person’s problem is classified within one of a set of recognized categories of abnormal behaviour and is labelled accordingly
Diagnosis should have “clinical utility” - meaning that it should help clinicians to determine the prognosis, treatment plans, and potential treatment outcomes for their patterns
Diagnosis Classification
Dimensional classification
Based on the premise that behaviour does not exist in categories but rather along dimensions
Mental disorders are examples of normal traits amplified to an extreme
Categorical classification
I.e., the DSM
The DSM is a categorical classification that divides mental disorders into types based on criteria sets with defining features
A categorical system works best when:
All members of a diagnostic class are homogeneous
When there are clear boundaries between classes
And when the different classes are mutually exclusive
The DSM5 System
The DSM is a system for diagnosing and classifying individuals who are exhibiting abnormal behaviours (thoughts and emotions)
Criteria for diagnosis is highly detailed and specific
Essential features - features that “define” it
Associated features- usually present
Diagnostic criteria- a list of symptoms (essential and associated) that must be present
Differential diagnosis- how to distinguish this disorder from others
Diagnostic Terms and Specifiers
Presenting Problem: the reason for the visit
The condition that is chiefly responsible for the ambulatory care medical services received during the visit
Principle Diagnosis: based on the presenting problem
When more than one diagnosis is given (i.e., comorbidity), the principle diagnosis is the condition that is primarily responsible for causing the individual to be admitted for care
Severity Specifiers: indicate the level of disability or impairment, rating the intensity, frequency, duration, symptom count
I.e., Mild, Moderate, Severe
Course Specifiers: indicate the progression of the illness
I.e., in partial remission, in full remission
The Old DSM System
The earlier DSM (fourth edition) was a multi-axial classification system
Five “axes” - each person is rated on five distinct dimensions (axes), each of which refers to a different domain in the person’s functioning
The Old DSM4 System
Five Axes of Diagnosis
Axis I: Clinical syndrome
Axis II: Personality disorders and Intellectual Disability
Axis III: General medical disorders
Axis IV: Psychosocial/environmental problems
Axis V- Global assessment of functioning
Culture and Diagnosis
Early editions of DSM were criticized for lack of consideration of culture and ethnicity
DSM-IV-TR introduced culture-bound syndromes:
Example: Koro- condition reported in south and east Asia intense anxiety that the penis or nipples will recede into the body, possibly leading to death
Culture- bound syndromes eliminated in DSM-5 replaced with “cultural syndromes”, “cultural idioms”, and “cultural explanations”
DSM-5 elaborated four specific themes to be considered in making cultural formulation:
Cultural identity
Cultural consideration of distress
Cultural features of vulnerability and resilience
Cultural features of the relationship between clinician and patient
Criticisms of Diagnosis
Once a person is diagnosed, it becomes a defining feature of their life- giving psychiatrists control over the person’s life
Creates false distinction between “normal” and “abnormal” (where do you draw the line on the fuzzy concepts such as “depression”)
When does a feature of “normal” become clinically significant?
Diagnosis creates an “artificial” boundary between different behaviourial categories (i.e., schizophrenia vs. depression) and people are often not just one or the other
Diagnosis is not explanation- diagnosing or labelling a person as “suffering from depression”- does not explain the underlying causes (but we think it does)
A diagnosis can reduce the person to an illness (mental health workers and/or society may just perceive the illness, and no longer see the person)
Rosenhan (1973)
Eight “pseudopatients” (three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife) - all clinically sane
Gained secret admission to 12 different hospitals
One symptom- Claimed to hear voices- the voices said “empty” or “hollow” or “thud”
Once admitted - the pseudopatients acted normally and reported no symptoms
Length of hospitalization ranged 5-52 days
Each was released with a diagnosis of “schizophrenia in remission”- none were classified as “sane”
Research Methods in Clinical Psychology
Science and Scientific Method
Testability and replicability
The role of theory
Research methods
The case study
Qualitative research
Epidemiological research
The correlation methods
The experimental methods
Single-subject experimental research
Mixed designs
Meta-analysis
Science and the Science of Methods
Science is the pursuit of systematized knowledge through observation
Latin scire- means “to know”
Testability and Replicability
A hypothesis must be amenable to systematic testing that could show it to be false
What is observed must be replicable
It must occur under prescribed circumstances not once, but repeatedly
The Role of Theory
Theory:
A set of propositions meant to explain a class of phenomena
The role of theory
Primary goal of science is to advance theories to account for data, often by proposing cause- effect relationships
Hypothesis
Expectations about what should occur if a theory is true
What criteria are applied in judging the legitimacy of a theoretical concept?
Operationism
Each concept takes as its meaning a single observable and measurable operation
Each theoretical concept would be nothing more than one particular measurable event
However, - if each theoretical concept is operationalized in only one way, it is generally lost
The need for multiple measures that tap into different facets of a concept
Case Studies
The detailed study of one individual, based on a paradigm
Providing detailed descriptions
Collecting historical and biographical information
Often includes details of therapy sessions
Several case studies can be compared and analyzed for common elements through a specific method
The case study as evidence
Particularly useful to negate a universal theory or law
Not useful to rule out alternative hypotheses
Generating hypothesis
Exposure to a large number of cases may allow the clinician to notice similarities of circumstances and outcomes in the life histories of clients
Psychotherapy training
Use in teaching practitioners to learn new techniques or therapeutic orientation
Qualitative Research
Qualitative research is similar to case study research in that the focus is on the unique and rich experiences of a small group of people who are studied in depth
Descriptive accounts with a subjective, idiographic emphasis are the focus rather than quantitative
Epidemiological Research
Epidemiology: Study of frequency and distribution of a disorder in a population
Data are gathered about the rates of a disorder and its possible correlates in a large sample or population
Provides a general picture of a disorder
Focusing on determining three features of a disorder:
Prevalence: Proportion of a population that has the disorder at a given point or period of time
Incidence: The number of new cases of the disorder that occur in some period, usually a year
Risk factors: Conditions or variables that, if present, increases the likelihood of developing the disorder
Knowledge about risk factors can give clues to the causes of disorders
Correlational Method
Is there a relationship between or among two or more variables?
Measuring correlation
Correlation coefficient ( r )
May take any value between +1 and -1
Measures magnitude and direction of relationship
Statistical significance
Likelihood results of an investigation are due to chance
Often set in psychology at p= .05
Applications of Correlational Methods to Psychopathology
Whenever we compare people given one diagnosis with those given another or with people without a psychological diagnosis, the study is correlational.
Often investigations in abnormal psychology re not recognized as correlational, perhaps because participants come to a laboratory for testing
Classificatory variables
Variables that are already present and are simply not measures by the researcher (i.e., disordered or not disordered, age, sex, social class, etc)
Limitations of Correlational Methods
Problems of causality
Critical drawback of correlational research
Does not allow determination of cause-effect relationships
Correlation between two variables tells us only that they are related or tend to co-vary with each
Directionality problem
How can we tell which is the cause and wich is the effect?
Correlation does not imply causation
Prospective, longitudinal design helps resolve the directionality issue
High-risk method: individuals with a predisposition are studied
Third variable problem
Some unforeseen factor that actually accounts for the correlation
Longitudinal Modelling and Group Trajectories
Developmental trajectory model
Collecting multiple observations of a particular behaviour over time (longitudinal)
Group-based trajectory modelling
Is based on evidence that it is impossible to distinguish clear subgroups of participants in a sample even though it really is important to distinguish these groups because:
Need to consider differing development factors
Best treatment options for people in subgroups
Use a complicated procedure called latent cass growth analysis to identify these subgroups and then use the multivariate statistical techniques to establish growth curves
Researchers using this approach can examine predictors of class membership as well as predictors of growth within a particular class
Intensive Longitudinal Designs
Experiencing samping is used to examine thoughts, feelings, and behaviours in their natural, spontaneous context
The data that result can show the unfolding of temporal within-person processes, both descriptively and in terms of causal analysis
Example is the link between daily triggering situations and subsequent body checking behaviours among people with anorexia nervosa
Experimental Methods
Gold standard for determining causality
Generally considered most powerful tool for determining causal relationships between events
Essentials of an experiment:
Random assignment of participants to different conditions
Manipulation of IV and measurement of DV
In the field of psychopathology the experiment is often used to evaluate the effects of therapies (e.g., RCTs)
Basic Features of Experimental Study Methods
Researcher typically begins with an experimental hypothesis
Investigator chooses an independent variable (IV) that can be manipulated (different conditions- often experimental vs control)
Participants are assigned to the conditions by random assignment
Researcher arranges for the measurement of a dependent variable (DV)
Analyze the data to determine if there has been an experimental
Single-Subject Experimental Designs
Participants are studied one at a time and experience a manipulated variable such as specific therapeutic treatment (there is no control group)
Reversal design or ABAB design
Measurement of a specific behaviour at different times:
During an initial time period (no treatment), the baseline (A)
During a period when treatment is introduced (B)
During a reinstatement of the condition that prevailed in the baseline period (A)
During the re-introduction of the experimental (treatment) manipulation (B)
The ABAB design is most appropriate when it is assumed that the effects of manipulations are temporary
Mixed Designs
The combination of experimental and correlational designs
Classificatory or correlational variables (e.g., having PTSD or not ) are not manipulated nor created by the researcher
Experiments demand the manipulation of a variable (e.g., three types of treatment for major depression)
Used in psychotherapy research
Involves the review of many studies in order to determine the effects of treatment
Interesting because it is a way to examining published and unpublished studies, and combining the results into a common format and then determining the extent of improvement, using a statistic called effect size
Lecture 4: Anxiety
Fear and Anxiety
Fear
A negative emotional state in response to real or perceived imminent threat to the self
Present focus
Anxiety
A negative emotional state that stems from anticipation of future threat to the self
Future focused
Both are adaptive and essential for survival
Components of Anxiety
Physiological
Heightened level of arousal and physiological activation
Examples: increased heart rate, shortness of breath, dry mouth
Cognitive
Subjective perception of anxious arousal and associated cognitive processes
Examples: worry and ruminations
Behavioural (Clinicians often add this component)
‘Safety’ behaviours
Avoidance
When does anxiety become a problem?
The anxiety must be chronic, relatively intense, associated with role impairment, and causing significant distress for self or others
What distinguishes chronically anxious people is their propensity to perceive threat and to be concerned/worried when there is no objective threat or the situation is ambiguous
Situational factors are important because it is normal to feel anxious in those situations that are truly upsetting or when there are actual threats to survival
Anxiety disorders can be associated with suicide attempts and suicidal thinking
Prevalence of Anxiety Disorders
12% of Cdnpopulation are struggling with an anxiety symptoms at any given time
Anxiety is often comorbid with depression
Co-occurence rates of 60%
Anxiety disorders are more common in women than in men across all age groups
International prevalence
One-year prevalence: 10.6%
Lifetime prevalence: 16.6%
Summary of Major anxiety Disorders
Specific Phobia- fear and avoidance of objects or situations that do not present any real danger
Social anxiety disorder- fear and avoidance of social situations due to possible negative evaluation from others
Panic disorder- recurrent panic attacks involving a sudden onset of physiological symptoms, such as dizziness, rapid heart rate, and trembling, accompanied by terror and feelings of impending doom
Agoraphobia- fear of being in public places
Generalized anxiety disorder- persistent, uncontrollable worry, often about minor things
Separation anxiety- the anxious arousal and worry about losing contact with and proximity to other people, typically significant others
Selective mutism- failure to speak in one situation (usually school) when able to speak in other situations (usually home)
Specific Phobia
Tend to be long-lasting
Mean duration of 20 years
Only 8% of people with a specific phobia received treatment
The most common specific phobia subtypes in order were:
Animal phobias (including insects, snakes, and birds);
Heights
Being in closed spaces
Flying
Being in or on water
Going to the dentist
Seeing blood or getting an injection
Storms, thunder, or lightning
Social Anxiety Disorder
Socially anxious people:
Are more concerned about evaluation than are people who are not socially anxious
Are highly aware of the image they present to others
Are high in public self-consciousness
Are preoccupied with a need to seem perfect and not make mistakes in front of other people
Tend to view themselves negatively even when they have actually performed well in a social interaction
Have excessive self-criticism
Etiology of Specific Phobias and Social Anxiety Disorder (SAD)
Behavioural theories
Avoidance conditioning
Modelling
Prepared learning
People with SAD have social skills deficits
Cognitive Theories
People who experience phobias or social anxiety disorder are more likely to:
Attend to negative stimuli;
Interpret ambiguous information as threatening; and
Believe that negative events are more likely than positive ones to re-occur
Engage in post-event processing of negative social experiences
Cognitive behavioural models link SAD with certain cognitive characteristics:
Attentional bias to focus on negative social information
Perfectionistic standards for accepted social performances
High degree of public self-consciousness
Biological Theories
Autonomic Nervous System (stability-liability)
Having a more liable ANS (jumpy individuals)
Genetic factors
No specific susceptibility genes have been found thus far
Psychoanalytic Theories
These theories about how someone develops phobias or social anxiety considered that phobias are a defence against the anxiety produces by repressed id impulses
Anxiety is displaced from the feared id impulse and moved to an object or situation that has some symbolic connection to it
These objects or situations then become the phobic stimuli
By avoiding them the person is able to avoid dealing with repressed conflicts
Panic Attack
A panic attack is not a mental disorder. But they can occur in the context of any anxiety disorder as well as other mental disorders and some medical conditions
When a panic attack occurs, it should be noted as a specifier (e.g., separation anxiety with panic attacks). For Panic disorder, the presence of panic attack is constrained within the criteria for the panic disorder
Person may also experience
Depersonalization (a feeling of being outside one’s body)
Derealization (a feeling of the world not being real, as well as fears losing control, of going crazy, or even dying)
Panic Attack
Often first recognized by complaints of having a heart attack
Two kinds of panic attacks
Unexpected- no obvious cue or trigger (out of the blue)
Expected0 an attack in response to a situational trigger (an obvious cue or trigger, such as previous situations where panic attacks have typically occurred)
Often comorbid with Agographobia
Panic Disorder with or without agoraphobia
Agoraphobia
From the greek agora, meaning “marketplace”
A cluster of fears centering on public places and being unable to escape or find help should one become incapacitated
Diagnosis requires anxiety at least 2 of 5 situations
Public transportation
Open spaces
Enclosed spaces
lines/crowds
Being out of the house alone
Many people with agoraphobia are unable to leave the house or do so only with great distress (karen from shameless)
Biological Theories of Panic Disorder
Physical conditions with panic-like symptoms
Mitral valve prolapse syndrome
Inner ear disease causes dizziness
Genetic factors
Panic disorder runs in families and has greater concordance in identical-twin pairs in fraternal twins
An increased risk of 5-16% among relatives of those with panic disorders
May be linked to “Val158Met COMT polymorphism” or other loci within or near the COMT gene
However, recent research failed to replicate COMT findings
Noradrenergic activity theory
Panic is caused by overactivity in the noradrenergic system:
Simulation of the locus ceruleus causes monkeys to have “panic attack”
In humans drugs that block firing in the locus ceruleus have not been found to be very effective in treating panic attacks
The role of gamma-aminobutyric acid (GABA) in panic:
GABA generally inhibits noradrenergic activity
Position emission tomography (PET) study found fewer GABA-receptor binding sites in people with Panic disorder
Therapeutic improvement involves changes in GABA receptors, but this applies to both anxiety and depression
Biological Theories of Panic Disorder
The role of Cholecystokinin (CCK) in Panic attacks
Peptide that occurs in the cerebral cortex, amygdala, hippocampus, and brain stem, induces anxiety-like symptoms in rats and effect can be blocked with benzodiazepines
A hypothesis is that panic disorder may be partly due to hypersensitivity to CCK
Exposure to CCK induces panic attacks and patients with panic disorder have a clear sensitivity to CCK
There is a genetic basis to CCK and its role in panic disorder
Psychological Theories of Panic Disorder
The fear-of-fear hypothesis
Suggests that agoraphobia is not a fear of public places per se, but a fear of having a panic attack in public
Misinterpretation of physiological arousal symptoms
Suggests that people who have autonomic nervous system that is predisposed to be overly active is couples with a psychological tendency to become very upset by these sensations
Generalized Anxiety Disorder (GAD)
Other features:
People with GAD do not typically seek psychological treatment
GADtypically begins in mid-teens
Stressful life events play role in onset
Highly comorbid with other anxiety disorders with mood disorders
Recent research has continued to question whether both “Excessive” and “uncontrollable” are necessary criteria for a diagnosis of GAD
It is difficult to treat GAD successfully
In one five-year follow-up study, only 18% of clients had achieved a full remission of symptoms
Etiology of GAD: Psychological Theories
Learning theories
Anxiety regarded as having been classically conditioned to external stimuli, but with a broader range of conditioned stimuli
Cognitive theories (cognitive vulnerability)
The perception of not being in control as a central characteristic of all forms of anxiety
The role of Intolerance Of Uncertainty in GAD
Related to the idea of control is the fact that predictable events produced less anxiety than do unpredictable events
Extensive research has shown the role of an intolerance of uncertainty in the experience of chronic worry and GAD
Uncertainty intolerance is particularly relevant when assessing ambiguous situations, and appraisals of ambiguous situations mediate the association between uncertainty intolerance and worry
Etiology of GAD: Psychological Theories
The role of Approach-Avoidance Conflicts in GAD
Two factor model of approach-avoidance:
Intolerance of uncertainty
Fear of anxiety
GAD-prone people with an intolerance of uncertainty have a desire t engage in approach behaviours to reduce their feelings of uncertainty
However, they are also characterized simultaneously by a fear of anxiety that promotes the use of avoidance strategies designed to limit the experience of anxious arousal
The role of worry as negative reinforcing in GAD:
Worry distracts people from negative emotions
Worry does not produce much emotional arousal
Worries do not produce the physiological changes that usually accompany emotion, and it actually blocks the processing of emotional stimuli
Therefore, by worrying people with GAD are avoiding certain unpleasant images and so their anxiety about these images does not extinguish
Metacognitive beliefs about worrying also play a role:
People can have positive beliefs about worry, such as “worrying helps to solve a problem”
People can also have negative beliefs about worry, such as “worrying is dangerous”
Metacognitive beliefs can increase worry and anxiety levels
Psychoanalytic Perspective of GAD
Unconscious conflict between the ego and id impulses
The impulses, usually sexual or aggressive in nature, are struggling for expression, but the ego cannot allow their expression because it unconsciously fears that punishment will follow
Since the source of anxiety is unconscious, the person experiences apprehension and distress without knowing why
The true source of anxiety, namely, desires associated with previously punished id impulses seeking expression- is everpresent
Biological Theories of GAD
Genetics
GAD may have a genetic component
Neuroniological model for GAD
Benzodiazepine medications are often effective in treating anxiety which suggests biological factors contribute to GAD
Receptor in the brain for benzodiazepines has been linked to the inhibitory neurotransmitter GABA
Benzodiazepines may decrease anxiety by increasing release of GABA
Drugs that block or inhibit the GABA system increase anxiety
Behavioural Treatment Approaches: Anxiety Disorders
Exposure therapy
Systematic desensitization was the first major behavioural treatment to be used widely in treating phobias. Involves progressive exposure to triggering stimuli
In vivo exposure treatment is often seen as superior using imagination
Virtual reality exposure
Modelling therapy for phobias
Fearful clients are exposed to filmed or live demonstrations of other people interacting fearlessly with the phobic object (e.g., handling snakes)
Social skills training for social anxiety disorder
Learning social skills to know what to say/do in social situations
Can be combined with exposure
Behavioural Treatment Approaches: GAD
It is difficult to find specific causes of the anxiety suffered by clients with GAD
Tend to prescribe more generalized treatment (intensive relaxation training), in the hope that if clients learn to relax when beginning to feel tense, their anxiety will be kept from spiraling out of control
Clients are taught to relax away low-level tensions, to respond to incipient anxiety with relaxation rather than alarm. This strategy is quite effective in alleviating GAD
Cognitive Treatment Approaches: Phobias
Cognitive treatments for specific phobias have been viewed with skepticism because of a central defining characteristic of phobias:
The phobic fear is recognized by the individual as excessive or unreasonable
If the person already acknowledges that the fear is of something harmless, what can it be to alter the person’s thoughts about it
There is no evidence that the elimination of irrational beliefs alone, without exposure to the fearsome situations, reduces phobic avoidance
Cognitive-Behavioural Therapies
Most commonly used CBT methods involve exposure and cognitive approaches
One well-validated exposure-based therapy developed by Barlow and his associates is called panic-control therapy
Panic control therapy has three principal components
Relaxation training
Cognitive restructuring
Exposure to the internal cues that trigger panic (which is termed- interoceptive exposure)
Psychoanalytic Treatments
Psychoanalytic therapies attempt to uncover the repressed conflicts believed to underline the extreme fear and avoidance characteristic of these disorders
Because the phobia itself was regarded as symptomatic of underlying conflicts, it is usually not dealth with directly
Indeed, direct attempts to reduce phobic avoidance were contraindicated because the phobia is assumed to protect the person from repressed conflicts that are too painful to confront
Many analytically oriented clinicians recognize the importance of exposure to what is feared, although they often regard any subsequent improvement as merely symptomatic and not as a resolution of the underlying conflict that was assumed to have produced the phobia
Lecture 5: Obsessive Compulsive and Related Disorders
Obsessive-Compulsive Disorder, Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania, Excoriation
The vicious cycle of OCD
Obsessive thought , anxiety, compulsive behaviour, temporary relief
Obsessive Compulsive Disorder (OCD)
OCD is a chronic disorder in which the mind is flooded with persistent and uncontrollable thoughts (obsessions) and the individual is compelled to repeat certain acts again and again (compulsions)
OCD affects men and women equally
Although it can occur in children, the typical age of onset is around 20 years of age
Late onset OCD (beyond early 30s) is very rare
OCD Specifiers
Many individuals with OCD have dysfunctional beliefs
Individuals with OCD vary in the degree of insight they have about the accuracy of the beliefs that underlie their obsessive-compulsive symptoms
“OCD with good or fair insight”- the individual recognizes that beliefs are definitely or probably not true or that they may or may not be true
“OCD with poor insight”- the individual thinks beliefs are probably true
“OCD with absent insight/delusional beliefs”- the individual is completely convinced that beliefs are true
What makes compulsions worse?
According to Rachman (2002), three “multipliers” that increase the intensity and frequency of compulsive checking are:
An inflated sense of personal responsibility
The probability of harm if checking does not take place
The predicted seriousness of harm
Behavioural and Cognitive Theories of OCD
Learned behaviours reinforced by fear reduction
Compulsive checking may result from memory deficit:
An inability to remember some action accurately (such as turning off the stove) or to distinguish between an actual behaviur and an imagined behaviour (“Maybe I just thought I turned off the stove”) could cause someone to check repeatedly
Possibly related to deficits in prospective memory (remembering to remember) and to non-verbal memory
Exposure and Response Prevention (ERP) for OCD
The person exposes themselves to situations that elicit the compulsive act- such as touching a dirty dish- then refrains from performing the accustomed ritual - hand washing
The assumption is that the ritual is negatively reinforcing because it reduces the anxiety that is aroused by some environmental stimulus or event, such as dust on a chair
Preventing the person from performing the ritual (response prevention) will expose him or to the anxiety provoking stimulus, thereby allowing the anxiety to extinguished
Inhibitory Learning Model
Effectively ERP helps people with OCD learn safety in a way that is strong enough to block (inhibit) the original fear
Focusing on anxiety tolerance instead of habituation
Disconfirming expectations
Surprise
Combining fear cues
Cognitive - Behavioural Approaches to Treatment for OCD
A combined CBT approach is clearly required when treating OCD rather than just a cognitive approach because an inherent part of any cognitive therapy is exposure and response prevention
To evaluate whether not performing a compulsive ritual will have catastrophic consequences, the client must stop performing that ritual
Cognitive procedures can eliminate the dysfunctional beliefs that contribute to the OCD clients’ faulty appraisals
An “inference-based approach”, is geared toward identifying and ameliorating the obsessional inference
Biological Theories of OCD
Genetic evidence
High rates of anxiety disorders occur among the first-degree relatives (10.3%) than control relatives (1.9%)
Brain structure
Encephalitis, head injuries, and brain tumours associated with the development of OCD
PET scan studies shown increased activation in the frontal lobes
PET findings show a link to the basal ganglia
A system linked to the control of motor behaviour
^ activation in basal ganglia, unclear if cause or consequence of OCD
Tourettes syndrome is marked by both motor and vocal tics and has been linked to basal ganglia dysfunction
People with Tourette’s often have OCD as well
Neuropsychological Testing Research
Patients with long-term OCD show attention and memory deficits
Meta-analysis findings by Synder et al., (2015) that patients with OCD show impairment in executive functions
Hypotheses related to SSRI drug treatment
Suggests OCD is related to decreased serotonin
However, 40-60% of OCD clients treated with SSRIs do not show improvement
Biological Approaches to Treatment for OCD
Brain surgery
Cingulotomy- involves destroying two to three centimetres of white matter in the cingulum, an area near the corpus callosum
Deep brain stimulation
Bilateral (not unilateral) subthalamic nucleus deep brain simulation is used for OCD treatment non-responders
Psychoanalytic Approaches to Treatment of OCD
Attempt to uncover the repressed conflicts
Resembles approach used for anxiety disorders (e.g., phobias)
The intrusive thoughts and compulsive behaviour protect the ego from the repressed conflict; however, they are difficult targets for therapeutic intervention
Psychoanalytic procedures have not been effective in treating this disorder
Hoarding Disorder
Characteristics of Hoarding Disorder
Frost and Gross (1993) defined hoarding as “the acquisition of and the failure to discard”
Hoarding disorder is associated with old age
Prevalence is estimated at 2%-5%, twice as prevalent as OCD
Genetic and moderate non-environmental correlations have been associated with difficulty parting with items and excessive acquisition of items
Etiology of Hoarding Disorder
Cognitive factors
Faulty information processing (i.e., distractibility and difficulty thinking about categories)
Erroneous cognitions about the importance and meaning of possessions
And misguided attachments with objects to seemingly compensate for emotional deficits in attachment to people
CBT for Hoarding Disorder
Previous studies of CBT for OCD found that those who also had hoarding symptoms showed poorer responses
Uses exposure aimed at not acquiring items as well as discarding items
Cognitive restructuring targets beliefs that are problematic for hoarding
Skills training which focuses on organizing, problem solving, and making decisions
Motivational interviewing techniques for ambivalence
Finally, the therapist makes home visit for more intensive exposure, lasting hours for some clients with severe hoarding
Body Dysmorphia Disorder (BDD)
A person is preoccupied with an imagined or exaggerated defect in appearance, frequently in the face; for example, facial wrinkles, excess facial hair, or the shape or size of the nose
Women tend also to focus on the skin, hips, breasts, and legs
Men are more inclined to believe they are too short, that their penises are too small, or that they have too much body hair
Treatment of BDD
Behavioural interventions typically focus on exposure and response prevention, similar to OCD
For example, staying in the situation without engaging in mirror checking
Cognitive strategies focus on identifying maladaptive, self-defeating thoughts, and core beliefs, such as “if i dont look perfect”, “its impossible to be happy” or “i’m unlovable”, that seem to maintain body-dysmorphic thoughts and behaviours;
Evaluating the accuracy of these negative thoughts and irrational beliefs;
Final sessions typically focus on relapse prevention
Body-Focused Repetitive Disorders
Trichotillomania (hair pulling disorder)
Excoriation (Skin Picking)
Etiology of Body-Focused Repetitive Disorders
Biological factors:
Genetics: trichotillomania and excoriation were found to be influenced by the same genetic factor, which was different than OCD, hoarding disorder, and BDD
Excess cortical thickness in areas related to inhibitory control has been implicated in trichotillomania
Excoration- ^ volume of the ventral striatum, compared to patients with trichotillomania.Possible involvement of the reward system with skin picking disorder
Trichotillomania - (downwards arrow) thickness of the right Para hippocampal gyrus. Possible link to dissociative symptoms
Emotion Regulation Model
Emotion regulation model states that hair-pulling and skin-picking behaviours are triggered by negative emotions
Hair-pulling and skin-picking behaviours serve to decrease the negative emotions, which in turn makes it more likely that the individual will engage in these behaviours (i.e., it is negatively reinforcing)
Frustrated Action Model
Hair-pulling and skin picking behaviours are triggered by frustration and boredom
Engaging in the behaviours alleviates these states, and so, similar to the emotion regulation model, the individual is more likely to engage in these behaviours
Therapy for Body-focused Repetitive Behaviours
Habit reversal training and other psychological treatments
Habit reversal is the behavioural treatment most often used for body-focused repetitive behaviour disorders and other impulse control disorders, although it has since been simplified and is often combined with cognitive techniques
One focus of habit reversal is awareness training
Involves the identification of triggers or high risk situations that often lead a person with one or both of these conditions to engage in hair-pulling and/or skin-picking
The Western and Eastern Perspective
Western Perspective:
Individualism and personal freedom are highly valued.
Emphasis on rationality, logic, and scientific inquiry.
Importance placed on material wealth and progress.
Democracy and human rights are central principles.
Christianity is the dominant religion.
Eastern Perspective:
Collectivism and community harmony are prioritized.
Emphasis on spirituality, intuition, and holistic thinking.
Focus on maintaining social order and hierarchy.
Buddhism, Hinduism, and Confucianism are influential religions.
Respect for elders and ancestral traditions is emphasized.