Obsessive Compulsive Disorder (OCD)

• OCD is categorized as obsessions with/without compulsive behaviours or thoughts.

  • Obsessions are ego-dystonic (intrusive, unwanted, or foreign) and recurring thoughts (feelings), images, or impulsives. Common themes cross-culturally include contamination, aggression, violence, religion, sexuality, and order.

    • Most individuals have multiple obsessions!

  • Compulsions are repetitive behaviours or mental acts that the individual is driven to perform. They usually follow from obsessions and serve the function of trying to neutralize obsessions, prevent feared events, or provide relief. Functionally they are related to obsessions, but they are not always logically related.

• Common features associated with OCD include mental rituals, fluctuating insight, family involvement in reinforcing obsessions/compulsions, avoidance (negative reinforcement), and reassurance-seeking.

  • OCD is often comorbid with other anxiety disorders!

• The lifetime prevalence is 3% with typical onset occurring in early adolescence or adulthood. The course of the disease is chronic and worsens the more you avoid it, however only 40% of people with OCD seek treatment.

• It is very commonly comorbid with anxiety and mood disorders, with 80% of people who have OCD also experiencing depression.

Mood Disorders

• The defining feature of mood disorders is extreme emotion.

  • Depression is profound sadness and dejection

  • Mania is intense, unfounded elation

• Unipolar mood disorders only have depressive episodes, while bipolar mood disorders have both depressive and manic episodes.

UNIPOLAR DEPRESSIVE DISORDERS

• Major depressive disorder, the most common unipolar depressive disorder, is characterized by a sad, depressed mood and a loss of interest/pleasure in things you used to be into. Other symptoms can include: sleep difficulties and fatigue, appetite problems, loss of sexual desire, psychomotor retardation, feelings of worthlessness and guilt, difficulty concentrating, and recurrent thoughts of death or suicide.

• Roughly 11% of people will experience depression in their lifetime and roughly 5% of the population has depression every year. 80% of people who experience one depressive episode will have another, with most people having an average of 4 episodes, each lasting 3-5 months on average (12% of episodes last 2+ years).

  • The kindling hypothesis says that each time you have an episode you are more likely to have another.

  • Episodes tend to cluster in high stress periods of life.

  • After 4-5 episodes, it is likely you will experience depressive episodes for the rest of your life because after multiple episodes not much stress is needed to trigger an episode.

• Persistent depressive disorder is a form of chronis (>2 years) low-grade depression with intermittent normal moods that lasts 4-5 years on average.

  • Double depression occurs when major depressive episodes are superimposed on persistent depressive disorder.

• People with depression will be likely to make attributions that are often negative and detrimental to their mental health. The table below shows possible attributions after a failed math test. Unstable, specific attributions are the easiest to overcome! Often people with depression make internal, stable, and global attributions.

• With MDD, there is a 2:1 ratio of women to men who have depression for a variety of reasons:

  • Women tend to have higher cortisol and ruminate more than men.

    • Higher cortisol has been shown to increase risk for relapse.

    • Rumination is a focus on distress and possible causes/consequences and it unproductive, repetitive, and passive. People who ruminate are 4x more likely to develop depression.

  • Women tend to have more interpersonal/emotionally intimate relationships and fall into caretaking roles more often.

  • Women experience different types of traumatic events more chronically including poverty, sexual harassment, and less power in intimate relationships

BIPOLAR DISORDERS

• Bipolar disorders are marked by both depressive and manic episodes.

  • Depressive episodes involve a low, sad mood and lack of interest or pleasure in previously pleasurable activities as well as the other symptoms of depression.

  • Manic episodes typically involved a marked increase in activity levels, unusual talkativeness, rapid and pressured speech, racing thoughts, less than usual amount of sleep needed without feeling tired, inflated self-esteem and belief that they have special talents, powers, and abilities, easily distractible, and excessive involvement in pleasurable activities that are likely to have undesirable consequences.

• Bipolar 1 disorder involves both manic and depressive episodes while Bipolar 2 involves shorter periods of mania and more depressive symptoms.

• Bipolar disorder is the disorder with the highest suicide risk, primarily because of the things done during manic episodes. It is also often associated with domestic violence, divorce, truancy, occupational failure, substance abuse, and episodic antisocial behaviour.

• The lifetime prevalence of Bipolar is 0.4-2.2% with no gender differences. Over 50% of people with bipolar will have 4+ episodes with the average age of onset being 18-22.

• With bipolar, people will have roughly 3:1 depresses versus manic days.

Suicide and Non-Suicidal Self-Injury

SUICIDE

• In canada there are over 10 suicides a day, with the overall base rate being 11.9/100,000 people. This rate doubles in old age and is insanely high in inuit communities (135-213/100,000)

• For every completed suicide, 20 people in the population attempt suicide

• Higher gun control is related to lower suicide rates due to less access to lethal weapons used to commit suicide.

• In youth, suicide is the 2nd leading cause of death, accounting for 24% of deaths in people 15-24 and 16% of deaths in people 25-44. However, suicide rates are actually highest for individuals 65+.

  • However, suicide rates are quickly rising in young people and tripped from the 1950s to the 1980s in people ages 15-24. The rates continue to rise.

  • The age at which youth start committing suicide is also getting younger.

  • 50% of suicidal adolescents and young adults do not use mental health services, however this number is probably higher than the research shows. The reasons for this are most likely parents, availability, fear of institutionalization, marginalization, and/or shame.

• With suicide, there are 6 stages of risk: ideation, urge, planning, preparation, intent, and action. Within therapy, ideation and urge are usually chronic but once a plan has been made, specifically a plan that is accessible, then suicide specific treatment is required.

  • Research shows that while ideation is much higher, the trends for youth who have a plan and who attempt suicide are almost identical, indicating the importance of treatment once a plan has been created.

• Men are 4x as likely to complete suicide and most often choose to use a gun or hang themselves while women are 3x as likely to attempt suicide but survive and often choose to overdose. These number are likely because of the different in lethality of the chosen methods.

• Suicide is comorbid with multiple mood and psychiatric disorders including bipolar disorder, conduct disorder, PTSD, intermittent explosive disorder, substance abuse, and panic disorder (specifically panic disorder + depression).

  • With mood disorders, individuals are at the highest risk of suicide when they are just coming out of depression. This is because they are still depressed, but they now have the energy to do something about it.

• While there are many risk factors that can contribute to suicide, it is very hard to predict when someone will kill themselves and it is hard to apply these risk factors to individuals. There are also low base rates of suicide. Furthermore, there are most factors that pose short-term risk while others pose long-term risk and all risk factors interact.

  • One way of predicting suicide is using an ITA which tests people to see how much they identify with suicide. High identity with suicide has been positively correlated with the likelihood of making an attempt in the next 6 months.

• There are also protective factors against suicide, with the largest being cognitive flexibility. Strong social support, hope, and receiving treatment for the underlying psychiatric disorder are also very promising protective factors.

• There are a lot of myths associated with suicide including: people who talk about it won’t do it; people who are suicidal always want to die; an improved mood means a decreased risk of suicide; suicidal ideation is rare; and asking about suicide might give them the idea/push them over the edge.

  • None of these myths are true.

• The reason most people commit suicide is to reduce suffering. The cause of the suffering itself is how bad you make that thing in your head, and it not necessarily related to what the thing actually is.

  • Other solutions to cease the pain without commiting suicide is to help reduce suffering, identify alternative options (cognitive flexibility), and to pull back even a little from the suicidal act.

• Joiner theorized that the desire for suicide comes from the perception of the self as a burden, the perception of not belonging, and the acquired capacity for suicide. When all of these factors align, there is a high risk for suicide completion or a serious attempt.

  • This theory also explains why self harm is related to suicide, in that it increases one’s tolerance for pain, in-turn increasing the acquired capacity for suicide.

• There are many ways to help prevent suicide, but the best thing you can do is crisis intervention.

  1. Validate emotional pain and understand what makes sense about the problem.

  2. Help clarify what the specific problem is and figure out what needs to be solved (must be something that can actually be solved).

  3. Accept that distress can be tolerated in this moment and will end.

  • It is also very important to maintain supportive contact, to encourage the person to seek professional help, and if needed reach out the the person’s family/friends.

• If an individual is at imminent risk for suicide, never leave them alone. If things start to seem better, have them create a plan of action for getting professional help and offer to accompany them. Also, have them commit to call you if they ever feel unsafe. If you are unable to stay with them or accompany them, have someone else be with them or take them to a public space.

NON-SUICIDAL SELF-INJURY

• Non-suicidal self-injury is self-inflicted damage to one’s own tissue without the intent to die.

• There is limited information about the prevalence of NSSI, especially because the definition for it is fuzzy and most data comes from hospitalizations. However, a large-scale community study of adolescents reported only 6% of individuals who engage in NSSI sought medical care.

  • Our best estimates is that NSSI is higher in females compared to males and the highest rates are in youth aged 8-24, with routhly 5-20% of college students engaging in NSSI. These numbers are likely due to the contagion effect, where individuals see others around them engaging in NSSI and then do it themselves.

    • Folks who engage in NSSI as teens are also likely to continue to engage in it when they do not receive proper treatment.

  • Canadian data shows a large increase in hospitalizations for NSSI between ages 15-19, but also a large discrepancy between females and males, with females being 3-5x more likely to engage in NSSI between 10-19 and only 0.25x more likely or less after age 20. This discrepancy is most likely due to the early onset of puberty in females.

• Approximately ½ of individuals who die by suicide have a history of NSSI. The most methods of NSSI a person uses, the more desensitized/habituated to pain they are, and therefore the most likely they are to be at a greater risk for suicide.

  • NSSI can also result in unintentional death, but this is not common.

• The psychological function of NSSI can be explain by the 4 factor model. The most powerful is negative, automatic and the second most powerful is negative social.

• With treatment for NSSI, it is important to treat the function of the behaviour!

  • Acceptance and commitment therapy is a common form of treatment that emphasizes unconditional acceptance of who you are and what you’re going through.

  • CBT for NSSI focuses on cognitive restructuring, however most kids dislike this.

  • DBT for NSSI focuses on emotion regulation and distress tolerance.

  • Motivational interviewing can also be used.

Eating Disorders

• There are three primary categories of eating disorders: binge eating disorder (BED), anorexia nervosa (AN), and bulimia nervosa (BN), however most people who have disordered eating don’t fall into one of these categories.

  • With eating disorders the primary concerns are maladaptive eating behaviours and the physiological/psychological consequences of these behaviours.

• Weight categories for eating disorders are based on medical models, primarily BMI which takes into account sex, height, and weight. The labels are: severely underweight, underweight, normal, overweight, and obese.

• Folks who have obsessive tendencies are more likely to develop eating disorders.

• The most critical element in most eating disorders, specifically AN and BN is body image dissatisfaction.

  • Sociocultural factors such as awareness of the “thin idea” in the media, internalization of the “thin idea” (worst one), and perceived pressure to be thin all influence this.

• Eating disorders have a 3:1 ration in women to men. When it comes to body dissatisfaction men tend to want to be more muscular and over exercise while women tend to want a smaller body and restrict eating.

  • Gay men tend report higher dierting frequency, fear of their body becoming overweight, body dissatisfaction, and the belief that potential partners prefer thinner bodies than oneself more than heterosexual men.

  • Lesbian adolescents tend to report lower body dissatisfaction and less internalization of the “thin ideal” than their straight counterparts.

• Different ethnicities also show differences in eating disorder attitudes and prevalence. Eating disorders are more common in asian and european countries. Different cultures also focus on different beauty ideals that may not be directly related to “thinness”. Eating disorders are also most common in industrial and urban settings.

  • Within western cultures BN is found much more commonly whereas AN is found equally across cultures.

• Within eating disorders it is likely that restrictive and binge-purge AN can cross over, or that BP AN can turn into BN. However, it’s rare that BN will turn into BP AN, usually due to larger weight. BN and BED are also commonly crossed over however its more common for BED to turn into BN than the other way around.

• ED’s are comorbid with depression, OCD, substance abuse disorders, and personality disorders (AN is comorbid with cluster C disorders and BN is comorbid with cluster B and C disorders)

• The best way to prevent ED’s is to focus on stamina and conditioning rather than body shape as well as stopping negative comments about body shape. Peer workgroups can also help to reduce teasing and focus on body shape evaluation

BINGE EATING DISORDER

• Binge eating disorder is characterized by frequent episodes of binge eating, a sense of lack of control over eating, and no behaviours to prevent weight gain.

• BED is associated with eating for emotional comfort, agitation during binges, dissociating or distracting during binges, self-disgust, guilt, or depression after a binge, and intense cravings for certain foods (usually high in carbs or sugar)

• The average age of onset of BED is 30-50.

• The best treatment for BED is SSRIs or appetite suppressant along with IPT (interpersonal therapy) and CBT (cognitive behavioural therapy)

ANOREXIA NERVOSA

• With AN, there is an an intense fear of becoming overweight and the pursuit of thinness.

• Anorexia is primarily characterised by a fear of gaining weight, refusal to maintain a health weight, and a distorted view of self/role of the body in self-worth.

  • Primarily the belief that self-worth is largely based on what you look like to others. This is usually seen through an overvaluation of shape and weight in self-worth.

• There are two types of AN: Restricting and Binge/Purge.

• AN is associated with dietary restrictions (e.g., counting calories or only eating “safe” foods), eating rituals, hoarding/concealing/discarding food, a preoccupation with food but anxiety about handling it, and efforts to conceal weight loss from others.

• AN had the highest rate of death of all mental health disorders, with 10% of people dying within 10 years of onset. The majority of people die from heart arrhythmia, malnutrition, or suicide. AN can also lead to kidney damage and failure as well as other long-term health effects.

  • The majority of people die during recovery from AN.

  • Suicide is the 2nd most common cause of death for patients with AN, with those people being 18x more likely than same age women in the population to commit suicide. It is highest when individuals are no longer a “low enough” weight or when they are older at first intervention/hospitalization.

• The average age of onset is 16-20.

BULIMIA NERVOSA

• With BN, there is an an intense fear of becoming overweight and the pursuit of thinness.

• BN is characterized by frequent episodes of binge eating, a lack of control over eating, recurrent compensatory behaviour to present weight gain, the maintenance of an average weight (or slightly overweight), and a distorted view of self/role of body in self-worth.

• There are two types of BN: purging and nonpurging. Most people with BN do a mix of both.

  • Purging entails using means like laxatives, diuretics, or throwing up to prevent weight gain.

  • Nonpurging entails using fasting ot excessive exercise to control caloric intake or weight gain.

• With BN, the first problem is usually restrictive eating with the goal to be thin, which leads to binging or eating restricted foods, which then leads to compensatory behaviour. This cycle tends to repeat itself.

  • When treating BN, it is important to first address the restricted eating, usually through cognitive therapy, which will then remove the rest of the cycle.

• BN is also associated with a preoccupation with food and/or weight, severe self-criticism, dietary restrictions in public (binges are almost always alone), frequent washroom visits after meals, and impulsivity.

• BN, like all eating disorders, can lead to a myriad of medical complications including electrolyte imbalances (which can be deadly) and damage to the heart, hands, throat, or teeth.

• While BN has a better prognosis than AN, there are often continued issues with rood after recover and 25-30% of people with BN attempt suicide. However, 70% of patients enter remission after 11-12 years.

• The average age of onset is 21-24.

ANOREXIA AND BULIMIA