OCD, PTSD, and Anxiety

Introduction

  • OCD and PTSD, once conceptualized as anxiety disorders, each get their own chapter in the DSM-5

  • How and why do we separate one disorder from another? Why do we construct distinct categories to explain suffering?

    • Is it because symptoms are different?

      • But what about symptom overlap?

    • Is it because each disorder would benefit from distinct treatment?

      • But what about treatment overlap?

    • Is it because the various disorders each have their own causes?

      • But we don’t know/agree on causes

  • Key question: when we categorize distress into different diagnostic labels, what are we seeking to accomplish? In other words, why do we create discrete disorders? What are the consequences of doing so?

Post Traumatic Stress Disorder (PTSD)

  • PTSD’s “long history” or not?

    • Are these all the same thing?

  • In a new chapter on “trauma and stress-related disorders”

  • To be diagnosed, a person (or loved one) must have been exposed to a traumatic event, involving actual or threatened death, serious injury, or sexual violation

    • Could have occured to others (ex. Witnessing or learning about it)

    • Could involve repeated exposure to details of event

      • But exposure can’t simply happen via electronic media (unless exposure work related)

  • Scope of PTSD has widened

    • Ex. ICD-11 introduces CPTSD, whereas DSM-5 has not

  • Four main DSM symptom clusters: re-experiencing, avoidance, arousal, and cognitive/mood changes

PTSD: 1. Re-experiencing

  • Person experiences feeling that event is reoccuring

    • Ex. Reliving experience, experiencing hallucinations, repetitive play, recurring dreams

  • Dissociative episodes, like flashbacks:

    • Can cause individual too feel detatched or unreal, have “déjà vu” or humbness to events

  • Person may experience distress if exposed to situation that may trigger re-experiencing

PTSD: 2. Avoidance and 3. Arousal

  • Avoidance of stimuli associated with the event (ex. Memories, people, objects, thoughts)

  • Increased arousal and anxiety

  • Recklessness, self-destructiveness

  • Sleep disturbances, trouble concentrating

PTSD: 4. Cognitive and Mood Changes

  • Cognitive and mood chages associated with PTSD, including:

    • Inability to recall specifics related to event

    • Estrangement

    • Anhedonia

    • Feeling that life is pointless or insignificant

    • Persistent feelings of fear, horror, anger, shame, guilt

  • Like most diagnositc categories, a great degree of heterogeneity possible among those diagnosed with PTSD

An Inconvenient Diagnosis 

  • Veterans’ groups pushed for inclusion in DSM-III (1980)

  • Governments often been reluctant to recognize PTSD, why?

    • Should we really be sending people off to fight?

    • Invincibility of soldiers?

    • Cost of treatment?

    • Malingering?

  • Now there is pressure within some militaries to rename it post traumatic stress injury. Why?

  • PTSD serves as a reminder that what counts as illness, how we define it, and who legitimizes it are all socially-dependent. Context matters!

Obsessive Compulsive Disorder

  • First “neuroses,” then “an anxiety disorder,” OCD independent in DSM-5

  • Obsessions: intrusive, recurring thoughts or images that a person struggles to resist, feeling anxiety over inability to control them

    • May result in physical/social/other consequences

    • Content often socially unacceptable

  • Compulsions: thoughts/actions that provide relief from obsessions

    • Often excessive, not realistically connected to obsession

    • Despite irrationality, difficult to resist

  • Recognition that thoughts are unreasonable

  • Only needs either obsessions or compulsions for diagnosis

Other OCD Related Disorders

  • Hoarding Disorder (persistent difficulty & distress discarding possessions due to perceived need).

    • Rather than intrusive thoughts, motivated by personal values, and distress over relinquishing objects others see as worthless.

  • Rachel Cooper: why does hoarding specifically deserve its own disorder?

    • Many other unwise habits go unpathologized.

    • What counts as “junk” is subjective.

    • Is this a medical problem? If hoarders had larger homes…

    • While some would say that a diagnosis is necessary to indicate that hoarding could be harmful, is a diagnosis necessary when laws already exist to deal w/ potential problems?

Somatic Symptom Disorder / Illness Anxiety Disorder

  • SSD’s key criteria:

    • At least one chronic somatic symptom that causes excessive preoccupation.

    • Symptoms usually medically unexplained, although excessive worry about explainable symptoms might be enough.

    • Although a person may frequently use healthcare services, they don’t necessarily feel better after doing so.

  • IAD’s key criteria:

    • Heightened bodily sensations.

    • Anxiety over potentially undiagnosed illness.

    • “Obsessive” research on illnesses and diseases.

    • Not easily reassured by physicians.

Problematizing SSD and IAD

  • Some critique the notion that the person’s problems do not have to be medically unexplained. Rather, it is a sign of mental illness if worry and thoughts are deemed “excessive.”

  • “What do we do w/ things that cannot be validated and seen by medicine (e.g. pain)?

  • Are we conditioned to obsess and worry over the body?

  • Why do we assume that people should always feel better after accessing healthcare?

Anxiety as a Multidimensional Pheomenon?

  • Some have suggested that OCD, PTSD, etc. should be thought of as anxiety disorders. Why?

    • Obsessions and compulsions usually accompanied by fear and distress, sometimes to the point of panic.

    • Centrality of avoidance.

    • In the same way that stress may increase anxiety, it might also increase the likelihood of intrusive thoughts or re-experiencing episodes.

    • OCD, PTSD, and anxiety disorders all have high co-morbidity w/ depression.  

    • OCD and anxiety disorders tend to respond to similar treatments.

  • In light of sharing so much w/ the anxiety disorders, should we understand these things as distinct?

The Case for Distinctness

  • Others: we should categorize distress in most precise and distinct way possible, separating PTSD and OCD from the anxiety disorders. Why?

    • Core symptoms (obsessiveness and re-experiencing) as unique.

      • Some secondary symptoms of OCD (e.g. magical thinking) also quite different.

  • Although anxiety often accompanies obsessions and reliving trauma, the same could be said for many mood disorders, substance use disorders, psychotic disorders, and so on. Following the logic of shared anxiety to its conclusion would mean erasing the boundaries between almost all disorders.

  • There are compelling arguments both for imagining all of these disorders as distinct from one another, as well as grouping them together as one.

    • Thus, we return to our key questions: why do we categorize psychological distress? What is gained in the process of delineating one disorder from another? What might be lost?

Conclusions: Does Categorization Matter?

  • In theory, categorization (in terms of where something appears in the DSM) shouldn’t really affect who is diagnosed.

    • What about diagnostic bias?

  • Categorization may affect how a disorder is understood and treated.

    • What type of interventions? What potential causes? Who should treat it? Being placed alongside another disorder within one chapter might shape how we think about a disorder.

  • Issues of identity and self-concept.

    • People often form identities around their disorders. E.g. the story of autism spectrum disorder.

  • Debates on categorization underscore the ways in which our ideas about mental disorders are constructed, subject to continual change.