RELATED DISORDERS OBSESSIVE-COMPULSIVE- RELATED AND TRAUMA- RELATED DISORDERS Obsessive-compulsive disorder and the trauma-related disorders are listed in the anxiety disorders chapter in the DSM-IV-TR.
OBSESSIVE-COMPULSIVE AND RELATED
DISORDERS We will focus on three disorders in this section: obsessive-compulsive disorder (OCD) body dysmorphic disorder hoarding disorder 1. OBSESSIVE-COMPULSIVE DISORDER
Obsessions are intrusive and recurring thoughts, images, or
impulses that are persistent and uncontrollable (i.e., the person cannot stop the thoughts) and that usually appear irrational to the person experiencing them Compulsions are repetitive, clearly excessive behaviors or mental acts that the person feels driven to perform to reduce the anxiety caused by obsessive thoughts or to prevent some calamity from occurring Pursuing cleanliness and orderliness, sometimes through elaborate rituals Repetitive checking to ensure that certain acts are carried out 1. OBSESSIVE-COMPULSIVE DISORDER OCD tends to begin either before age 10 or else in late adolescence/early adulthood Common among women Two-thirds meet criteria for major depression during their lifetime. Substance use is also common About one-third of people with OCD experience at least some symptoms of hoarding Proposed DSM-5 Criteria for OBSESSIVE-COMPULSIVE DISORDER 1. Obsessions (recurrent, intrusive, persistent, unwanted thoughts, urges, or images that the person tries to ignore, suppress, or neutralize) or
2. Compulsions (repetitive behaviors or thoughts that a
person feels compelled to perform to prevent distress or a dreaded event or in response to an obsession)
3. The obsessions or compulsions are time consuming (e.g.,
require at least 1 hour per day) or cause clinically significant distress or impairment Etiology of OCD There is no absolute signal from the environment. Rather, most of us stop when we have the sense of that is enough. Yedasentience is defined as this subjective feeling of knowing Behavioral models emphasize operant conditioning of compulsions. That is, compulsions are reinforced because they reduce anxiety Thought suppression 2. BODY DYSMORPHIC DISORDER preoccupied with an imagined or exaggerated defect in their appearance On average, people with BDD think about their appearance for 3 to 8 hours per day BDD occurs slightly more often in women The most common comorbid disorders include major depressive disorder, social anxiety disorder, obsessive- compulsive disorder, substance use disorders, and personality disorders Proposed DSM-5 Criteria for BODY DYSMORPHIC DISORDER
1. Preoccupation with a perceived defect or in appearance
2. The person has performed repetitive behaviors or mental
acts (e.g., mirror checking, seeking reassurance, or excessive grooming) in response to the appearance concerns
3. Preoccupation is not restricted to concerns about
weight or body fat ETIOLOGY OF BDD
When looking at visual stimuli, people with BDD appear
to focus on details more than on the whole
Indeed, many people with BDD seem to believe that their
self-worth is exclusively dependent on their appearance 3. HOARDING DISORDER Hoarding disorder, the need to acquire is only part of the problem. The bigger problem is that they abhor parting with their objects, even when others cannot see any potential value in them Although hoarding is more common among men than among women The accrual of objects often overwhelms the persons home. Hoarding was not recognized as a diagnosis until the DSM-5. Although hoarding is often comorbid with OCD, it can also occur among those who do not have OCD symptoms. Depression, generalized anxiety disorder, and social phobia are common among people diagnosed with hoarding Hoarding develops among people with schizophrenia or dementia Proposed DSM-5 Criteria for HOARDING DISORDER 1. Persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions
2. Strong urges to save items and/or distress associated
with discarding
3. The symptoms result in the accumulation of a large
number of possessions that clutter key areas the home or workplace to the extent that their intended use is no longer possible unless others intervene. ETIOLOGY OF THE OBSESSIVE COMPULSIVE AND RELATED DISORDERS Brain-imaging studies indicate that three closely related areas of the brain are unusually active in people with OCD the orbitofrontal cortex (an area of the medial prefrontal cortex located just above the eyes), the caudate nucleus (part of the basal ganglia), and the anterior cingulate ETIOLOGY OF HOARDING DISORDER In considering hoarding, many take an evolutionary perspective (Zohar & Felz, 2001).
According to the cognitive behavioral model, hoarding is
related to poor organizational abilities, unusual beliefs about possessions, and avoidance behaviors (Steketee & Frost, 2003) TREATMENT OF THE OC AND RELATED DISORDERS Each of these disorders responds to serotonin reuptake inhibitors. The major psychological approach is exposure and response prevention, although this treatment is tailored for the specific conditions. The most commonly prescribed SRI for OCD is clomipramine (Anafranil; McDonough & Kennedy, 2002) Selective serotonin reuptake inhibitors (SSRIs) are a newer class of SRIs that have fewer side effects. Patients with hoarding disorder demonstrated as much of a response to the SSRI paroxetine (Paxil) as did those with OCD (Saxena, Brody, Maidment, et al., 2007). PSYCHOLOGICAL TREATMENT The most widely used psychological treatment for the obsessive- compulsive and related disorders is exposure and response prevention (ERP). This cognitive behavioral treatment was pioneered in England by Victor Meyer (1966) as an approach for OCD. Several trials have shown that cognitive behavioral treatment (CBT) produces a major decrease in body dysmorphic symptoms compared to control conditions (Looper, 2002) Hoarding Disorder Treatment for hoarding is based on the ERP therapy that is employed with OCD POSTTRAUMATIC STRESS DISORDER AND ACUTE STRESS DISORDER PTSD Posttraumatic stress disorder (PTSD) entails an extreme response to a severe stressor, including increased anxiety, avoidance of stimuli associated with the trauma, and symptoms of increased arousal In addition to PTSD, the DSM includes a diagnosis for acute stress disorder (ASD). ASD is diagnosed when symptoms occur between 3 days and 1 month after a trauma. The symptoms of ASD are fairly similar to those of PTSD, but the duration is shorter. Culture also may shape the types of symptoms observed in PTSD. Ataque de nervios, originally identified in Puerto Rico, involves physical symptoms and fears of going crazy in the aftermath of severe stress and thus is similar to PTSD Proposed DSM-5 Criteria for POSTTRAUMATIC STRESS DISORDER A. The person was exposed to death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: experiencing the event personally, witnessing the event, learning that a violent or accidental death or threat of death occurred to a close other, or experiencing repeated or extreme exposure to aversive details of the event(s) B. At least 1 of the following intrusion symptoms: 1. Recurrent, involuntary, and intrusive distressing memories of the trauma, or in children, repetitive play regarding the trauma themes 2. Recurrent distressing dreams related to the event(s) 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the trauma(s) were recurring 4. Intense or prolonged distress or physiological reactivity in response to reminders of the trauma(s) Proposed DSM-5 Criteria for POSTTRAUMATIC STRESS DISORDER C. At least 1 of the following avoidance symptoms: 1. Avoids internal reminders of the trauma(s) 2. Avoids external reminders of the trauma(s) D. At least 3 (or 2 in children) negative alterations in cognitions and mood that began or worsened after the trauma(s): 1. Inability to remember an important aspect of the trauma(s) 2. Persistent and exaggerated negative expectations about ones self, others, or the world 3. Persistently excessive blame of self or others about the trauma(s) 4. Pervasive negative emotional state 5. Markedly diminished interest or participation in significant activities 6. Feeling of detachment or estrangement from others 7. Persistent inability to experience positive emotions Proposed DSM-5 Criteria for POSTTRAUMATIC STRESS DISORDER E. At least 3 (or 2 in children) of the following alterations in arousal and reactivity that began or worsened after the trauma(s): 1. Irritable or aggressive behavior 2. Reckless or self-destructive behavior 3. Hypervigilance 4. Exaggerated startle response 5. Problems with concentration 6. Sleep disturbance F. The symptoms began or worsened after the trauma(s) and continued for at least one month DSM-IV-TR Criteria for ACUTE STRESS DISORDER
1. Exposure to a traumatic event causing extreme fear,
helplessness, or horror 2. During or after the event, the person experiences dissociative symptoms 3. The event is reexperienced intrusively in dreams, thoughts, or intense reactivity to reminders 4. The person feels numb, detached, or unable to remember the event 5. Increased arousal or anxiety 6. Symptoms occur within the first month after the trauma DSM 5-TR Criteria for ACUTE STRESS DISORDER A. The person was exposed to death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: experiencing the event personally, witnessing the event, learning that a violent or accidental death or threat of death occurred to a close other, or experiencing repeated or extreme exposure to aversive details of the event(s) B. At least 8 of the following symptoms began or worsened since the trauma and lasted 3 to 31 days: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event 2. Recurrent distressing dreams related to the traumatic event DSM 5-TR Criteria for ACUTE STRESS DISORDER 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event were recurring 4. Intense or prolonged psychological distress or physiological reactivity at exposure to reminders of the traumatic event 5. Subjective sense of numbing, detachment from others, or reduced responsiveness to events 6. Altered sense of the reality of ones surroundings or oneself (e.g., seeing oneself from anothers perspective, being in a daze) 7. Inability to remember at least one important aspect of the traumatic event 8. Avoids internal reminders of the trauma(s) 9. Avoids external reminders of the trauma(s) 10. Sleep disturbance 11. Hypervigilance 12. Irritable or aggressive behavior 13. Exaggerated startle response 14. Agitation or restlesssness ETIOLOGY OF PTSD two-thirds of people who develop PTSD have a history of another anxiety disorder. high levels of activity in areas of the fear circuit such as the amygdala (Rauch, 2000), childhood exposure to trauma (Breslau, 1995), and tendencies to attend selectively to cues of threat PTSD has been related to the two-factor model of conditioning. PTSD appears uniquely related to the function of the hippocampus. (SMALLER) The hippocampus is known for its role in memory, particularly for memories related to emotions TREATMENT OF PTSD AND ASD
One class of antidepressant, the selective serotonergic
reuptake inhibitors (SSRIs), has received strong support as a treatment for PTSD.
Relapse is common if medications are discontinued.
PSYCHOLOGICAL TREATMENT OF PTSD In PTSD, the focus of exposure treatment is on memories and reminders of the original trauma, with the person being encouraged to confront the trauma to gain mastery and extinguish the anxiety. Where possible, the person is directly exposed to reminders of the trauma in vivofor example, by returning to the scene of the event.
In other cases, imaginal exposure is usedthe person
deliberately remembers the event
Therapists have also used virtual reality (VR) technology to treat
PTSD, because this technology can provide more vivid exposure than some clients may be able to generate in their imaginations. PSYCHOLOGICAL TREATMENT OF ASD Short-term (five or six session) cognitive behavioral approaches that include exposure appear to do so.
The positive effects of these early interventions appear to
last for years
Exposure treatment appears to be more effective than
cognitive restructuring in preventing the development of PTSD