Clinical psychology
Chapter 7
Obsessive-compulsive-related and trauma-related disorders

Obsessive-compulsive and related disorders

OCD is defined by repetitive thoughts and urges (obsessions) as well as an irresistible need to engage in repetitive behaviors or mental acts (compulsions)

Body dysmorphic disorder and hoarding disorder have symptoms or repetitive thoughts and behaviors.

• People with body dysmorphic disorder spend hours a day thinking about their appearance, and almost all engage in compulsive behaviors such as checking their appearance in the mirror.
• People with hoarding disorder spend a good deal of their time repetitively thinking about their current and potential future possessions. They also engage in intensive efforts to acquire new objects, and these efforts can resemble the compulsions observed in OCD.

For all three conditions, the repetitive thoughts and behaviors are distressing, feel uncontrollable, and require a considerable amount of time.
For the person with these conditions, the thoughts and behaviors feel unstoppable.

These syndromes often co-occur.

Clinical descriptions and epidemiology of the obsessive-compulsive and related disorders

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is characterized by obsessions or compulsions.

Obsessions: intrusive and recurring thoughts, images, or impulses that are persistent and uncontrollable and often appear irrational to the person experiencing them.
For people with OCD, obsessions have such force and frequency that they interfere with normal activities.
People with obsessions may also be prone to extreme doubts, procrastination, and indecision.

Compulsions: 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.
Even though rationally understanding that there is no need for this behavior, the person feels as something dire will happen if the act is not performed.
The sheer frequency with which compulsions are repeated may be staggering.
Commonly reported compulsions:

• Pursuing cleanliness and orderliness, sometimes through elaborate rituals- performing repetitive , magically protective acts, such as counting or touching a body part.
• Repetitive checking to ensure that certain acts are carried out.

OCD tends to begin either before age 10 or else in late adolescence/early adulthood.
Slightly more common among women than men.
The pattern of symptoms appears to be similar across cultures.
High comorbidity.

DSM-5 criteria for Obsessive-compulsive disorder

• Obsessions or compulsions
• Obsession are defined by
  • Recurred, intrusive, persistent, unwanted thoughts, urges or images
  • The person tries to ignore, suppress, or neutralize the thoughts, urges, or images
• Compulsions are defined by
  • Repetitive behaviors or thoughts that the person feels compelled to perform to prevent distress or a dreaded event.
  • The person feels driven to perform the repetitive behaviors or thoughts in response to obsessions or according to rigid rules
• The obsessions or compulsions are time consuming (at least 1 hour per day) or cause clinically significant distress or impairment.

Body dysmorphic disorder

People with body dysmorphic disorder (BDD) are preoccupied with one or more imagined or exaggerated defects in their appearance.

• Women are tend to focus on their skin, hips, breast, and legs.
• Men are tend to focus on their height, penis size, or body hair.

People with BDD find it very hard to stop thinking about their concerns. On average, people with BDD think about their appearance for 3 to 8 hours a day.
People with BDD find themselves compelled to engage in certain behaviors.

In BDD the most common compulsive behaviors include:

• Checking their appearance in the mirror
• Comparing their appearance to that of other people
• Asking others for reassurance about their appearance
• Using strategies to change their appearance or camouflage disliked body parts.

While many spend hours a day checking their appearance, some try to avoid being reminded of their perceived flaws.
People with BDD spend an inordinate amount of time and energy on these endeavors.

The symptoms are extremely distressing.

Slightly more in women than in men, but even among women it is relatively rare, with a prevalence of less than 2 percent.
Typically begins in late adolescence.
Not chronic.
Social and cultural factors surely play an role in how people decide whether they are attractive. Symptoms and outcomes of BDD are similar across cultures.
But body parts that becomes a focus of concern sometimes differ by culture.

Nearly all people with BDD meet the diagnostic criteria for another disorder.
Most common comorbid disorders include:

• Major depressive disorder
• Social anxiety disorder
• Obsessive-compulsive disorder
• Substance use disorders
• Personality disorders

Clinicians should consider whether the symptoms are better explained by an eating disorder.

DSM-5 criteria for body dysmorphic disorder

• Preoccupation with one or more perceived defects in appearance
• The person has performed repetitive behaviors or mental acts in response to the appearance concerns
• Preoccupation is not restricted to concerns about weight or body fat.

Hoarding disorder

For people with harding 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.
People with hoarding disorder are extremely attached to their possessions, and they are very resistant to efforts to get rid of them.

1/3 of people with hoarding disorder, much more often women than men, also engage in animal hoarding. They often view themselves as animal rescuers.

The consequences of hoarding can be quite severe.

• The accrual of objects often overwhelms the person’s home.
• Poor physical health due respiratory conditions, poor hygiene, and difficulty cooking.
• Excessive buying and/or unable to work.

More common among men than women, but very few men seek treatment.
Typically begins in childhood or early adolescence. These early symptoms may be kept under control by parents and by limited income, so severe impairment for the hoarding disorder often does not surface until later in
life.
Animal hoarding disorder does not emerge until middle age or older.

Often comorbid with OCD.
Depression, generalized anxiety disorder, and social phobia are common among people diagnosed with hoarding.
Occasionally, hoarding symptoms develop among people with schizophrenia or dementia.
When symptoms are better explained by another disorder, hoarding disorder should not be diagnosed.

DSM-5 criteria for hoarding disorder

• Persistent difficulty discarding or parting with possessions, regardless of their actual value
• Perceived need to save items
• Distress associated with discarding
• These symptoms result in the accumulation of a large number of possessions that clutter active living spaces to the extent that their intended use is compromised unless others intervene.

Etiology of the obsessive-compulsive and related disorders

Obsessive-compulsive disorder, body dysmorphic disorder, and hoarding disorder share some overlap in etiology.

• This overlap might be due to genetic and neurobiological risk factors.
  OCD and BDD seem to involve some of the same brain regions.
  Three closely related areas of the brain are unusually active in people with OCD.
  • The oritofrontal cortex (an area of the medial prefrontal cortex located just above the eyes)
  • The caudate nucleus (part of the basal ganglia)
  • The anterior cingulate

BDD appears to be related to hyperactivity of the orbitofrontal cortex and the caudate nucleus.

Cognitive behavioral models focus on factors that might promote one disorder as compared to the other.

Etiology of obsessive-compulsive disorder

There is a moderate genetic contribution to OCD, with estimates of heritabilty ranging from 30 to 50 percent.

Yedasentience: the sense of ‘that is enough’ and then stop. This subjective feeling of just knowing.

Theory: people with OCD suffer from a deficit in yedasentience.
Objectively, they seem to know that there is no need to continue the activity, but they suffer from an anxious internal sense that things are not complete.

Other cognitive behavioral models tend to provide distinct explanations for compulsion versus obsessions.

• Pperant conditioning for compulsions.
  Compulsions are reinforced because they reduce anxiety
  And lack of confidence regarding memory → repeat action
• Obsessions
  People with OCD may try harder to suppress their obsessions than other people and, in doing so, may actually make the situation worse.
  Also deep feeling of responsibility for what occurs.
  As a consequence of these two factors, they are more likely to attempt thought suppression.
  Trying to suppress a thought may have the paradoxical effect of inducing preoccupation with it. The effects of trying to suppress a thought can continue for days.
  People with OCD tend to give more reasons why they should try to suppress thoughts than do people without OCD.

Etiology of body dysmorphic disorder

People with BDD seem to be able to accurately see and process their physical features.
But those with BDD are more attuned to features that are important to attractiveness, than those without BDD.

When looking at a stimuli, people with BDD appear to focus on details more than on the whole.
They examine one feature at a time, which makes it more likely that they will become engrossed in considering a small flaw.
They also consider attractiveness to be vastly more important. Many people with BDD seem to believe that their self-worth is exclusively dependent on their appearance.
Because of the importance of appearance, people with BDD tend to spend a lot of time focusing on their appearance, to the exclusion of focusing on other, more positive stimuli.

Etiology of hoarding disorder

The cognitive behavioral model suggests a number of factors that might be involved.

• Poor organizational abilities
• Unusual beliefs about possessions
• Avoidance behaviors

Treatment of the obsessive-compulsive and related disorders

Treatment for OCD, body dysmorphic disorder, and hoarding disorder are similar.

• Each of these disorders responds to serotonin reuptake inhibitors
• The major psychological approach is to exposure and response prevention, although this treatment is tailored for the specific conditions.

Medications

Antidepressants are the most commonly used medications for the obsessive-compulsive and related disorders.
They are effective for the treatment of OCD and BDD.

• The most commonly prescribed antidepressant for OCD is clomipramine
• Selective serotonin inhibitors (SSRIs) have fewer side effects. Appear to be effective in the treatment of OCD and BDD.

Most studies indicate that hoarding symptoms respond less to medication treatment than do other OCD symptoms.

Psychological treatment

The most widely used psychological treatment for the OCD and related disorders is exposure and response prevention (ERP).

Obsessive-compulsive disorder
In the response prevention component of ERP, people exposure themselves to situations that elicit the compulsive act and then refrain from performing the compulsive ritual.
Reasoning:

• Not performing the ritual exposes the person to the full force of the anxiety provoked by the stimulus
• Exposure results in the extinction of the conditioned response.

EPR is highly effective in reducing obsessions and compulsions. More effective than clomipramine for the treatment of OCD. Effective for children adolescents as well as adults.
Even though most people experience a clinically significant reduction in symptoms with ERP, some mild symptoms are likely to remain.

Cognitive approaches to OCD focus on challenging people’s beliefs about what will happen if they do not engage in rituals.
Eventually, to help test such beliefs, these approaches will use exposure.
Perform as well as ERP.

Body dysmorphic disorder
The basic principles of ERP are tailored in several ways to address the symptoms of BDD.
For example, people might be asked to interact with people who could be critical of their looks.
For response prevention, clients are asked to avoid these activities they use to reassure themselves about their appearance.
These behavioral techniques are supplemented with strategies to address the cognitive features of the disorder.
Cognitive behavioral treatment produces a major decrease in BDD.
Treatments that include a cognitive component are more powerful than those that address only behaviors. Both treatments produce lasting effects.

Hoarding disorder
Treatment for hoarding disorder is based on the ERP therapy that is employed with OCD.
The exposure element of treatment focuses on getting rid of objects.
Response prevention focuses on halting the rituals that they engage in to reduce their anxiety, such as counting or sorting their possessions.

Despite the common elements, treatment is tailored in many ways for hoarding.
Many people with hoarding disorder don’t recognize the gravity of problems created by their symptoms. Therapy cannot begin to address the hoarding symptoms until the person develops insight.
Motivational strategies are used to help the person consider reasons to change.
Once people decide to change, therapists help them make decisions about their objects, provide them tools to help them get their clutter organized, and schedule sessions to work on the ‘de-cluttering’.
The therapists supplement their office sessions with in-home visits.

Posttraumatic stress disorder

Posttraumatic stress disorder and acute stress disorder are diagnosed only when a person has experienced a traumatic event.
The criteria of these diagnoses incorporate the cause of symptoms.

Clinical description and epidemiology of postraumatic stress disorder and acute stress disorder

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.
Diagnoses of these disorders are considered only in the context of serious traumas.

In the DSM-5, the symptoms for PTSD are grouped into four major categories:

• Intruively reexperiencing the traumatic event.
• Avoidance of stimuli associated with the event
• Other signs of mood and cognitive change after the trauma
• Symptoms of increased arousal and reactivity

Once PTSD develops, symptoms are relatively chronic.
Suicidal thoughts are common among people with PTSD, as are incidents of nonsuicidal self-injury.

Acute stress disorder (ASD) is diagnosed when symptoms occur 3 days and 1 month after trauma.
The symptoms of ASD are fairly similar to PTSD, but the duration is shorter.

Two major concerns about the ASD diagnoses:

• It could stigmatize short-term reactions to serious traumas, even though these are quite common.
• Most people who go on to meet diagnostic criteria for PTSD do not experience ADS in the first month after the trauma.

PTSD tends to be highly comorbid with other conditions. Most common disorders are other anxiety disorders, major depression, substance abuse, and conduct disorder.
Women are twice at likely to develop PTS as are men.
Culture may shape the risk for PTSD in several ways.

• Some cultural groups may be exposed to higher rates of trauma and, as a consequence, manifest higher rates of PTSD.
• Culture may shape the types of symptoms observed in PTSD.

DSM-5 criteria for Posttraumatic stress disorder

• A.
  • The person was exposed to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: experiencing the event personally, witnessing the event in person, 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) other than through media.
• B. At least 1 of the following:
  • Recurrent, involuntary, and intrusive distressing memories of the trauma, or in children, repetitive play regarding the trauma themes.
  • Recurrent distressing dreams related to the event(s)
  • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the trauma(s) were recurring, or in children, re-enactment of trauma during play
  • Intense or prolonged distress or physiological reactivity in response to reminders of the trauma(s)
• C. At least 1 of the following avoidance symptoms:
  • Avoids internal reminders of the trauma(s)
  • Avoids external reminders of the trauma(s)
• D. at least 2 of the following negative alterations in cognitions and mood:
  • Inability to remember an importation aspect of the trauma(s)
  • Persistent and exaggerated negative beliefs or expectations about one’s self, others, or the world
  • Persistently excessive blame of self or others about the trauma(s)
  • Persistently negative emotional state, or in children younger than 7, more frequent negative emotions
  • Markedly diminished interest or participation in significant activities
  • Feeling of detachment or estrangement from others, or in children younger than 7, social withdrawal
  • Persistent inability to experience positive emotions
• E. At least 2 of the following alterations in arousal and reactivity:
  • Irritable or aggressive behavior
  • Reckless or self-destructive behavior
  • Hypervigilance
  • Exaggerated startle response
  • Problems with concentration
  • Sleep disturbance
• F.
  The symptoms began or worsened after the trauma(s) and cotinued for at least on month
• G.
  Among children younger than 7, diagnoses requires criteria A, B, E, and F, but only 1 symptom from either category C or D.

DSM-5 criteria for acute stress disorder

• A.
  Exposure to actual or threatened death, serious injury, or sexual violation, in one for more of the following ways: experiencing he event personally, witnessing the even, learning that a violent or accidental death or treat of death occurred to a close other, or experiencing repeated or extreme exposure to aversive details of the event(s) other than through media exposure.
• B.
  At least 8 of the following symptoms began or worsened since the trauma and lasted 3 to 31 days:
  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event, or children repetitive play involving aspects of the traumatic event.
  • Dissociative reactions (e.g. Flashbacks) in which the individual feels or acts as if the traumatic event were recurring, or inc children, re-enactment of trauma during play.
  • Intense or prolonged psychological distress or physiological reactivity at exposure to reminders of the traumatic event
  • Persistent inability to experience positive events
  • Altered sense of reality of one’s surroundings or oneself
  • Inability to remember an important aspect of the traumatic event
  • Avoids internal reminders of the trauma(s)
  • Avoids external reminders of the trauma(s)
  • Sleep disturbance
  • Hypervigilance
  • Irritable or aggressive behavior
  • Exaggerated startle response
  • Agitation or restlessness
  • Problems with concentration.

Etiology of posttraumatic stress disorder

Two-thirds of people who develop PTSD have a history of another anxiety disorder.
Many of the risk factors for PTSD overlap with the risk factors for other anxiety disorder.

• PTSD is related to genetic risk for anxiety disorders
• High levels of activity in areas of the fear circuit as the amygdala
• Childhood exposure to trauma
• Tendencies to attend selectively to cues of threat.

Neuroticism and negative affectivity predict the onset of PTSD.
PTSD has been related to the two-factor model of conditioning.

Nature of the trauma: severity and the type of trauma matter

The severity of trauma influences whether or not a person will develop PTSD.
Among people who have been exposed to trauma, those exposed to the most severe traumas seem most likely to develop PTSD.

Beyond severity, the nature of traumas matters.
Traumas caused by humans are more likely to cause PTSD than are natural disasters.
It may be that these events are seen as more distressing because they challenge ideas about humans as benevolent.

Neurobiological factors: hippocampus and hormones

PTSD appears to be related to greater activation of the amygdala and diminished activation of the medial prefrontal cortex.
PTSD appears to be uniquely related to the function of the hippocampus.
Smaller-than-average hippocampal volume might precede the onset of disorder.

Coping

When faced with a traumatic event, some people seem to rise to the challenge and show extraordinary resilience.
How a person copes during the trauma and afterwards helps predict whether PTSD will develop.

People who cope with a trauma by trying to avoid thinking about it are ore likely to develop PTSD.
More dissasociation (like feeling removed from one’s body or emotions, or being unable to remember the event)

Two protective factors:

• High intelligence
• Strong social support

Treatment of posttraumatic stress disorder and acute stress disorder

Medications

Selective serotonergic reuptake inhibitors
But relapse is common if medications are discontinued

Psychological treatment of posttraumatic stress disorder

Exposure treatment with focus on memories and reminders of the original trauma, with the person being encouraged to confront the trauma to gain mastery and extinguish the anxiety.

• In vivo
• Imaginal exposure

Exposure treatment is more effective than medication or supprotive unstructured psychotherapy.

Several cognitive strategies have been used to supplement exposure treatment for PTSD.
Interventions designed to bolster people’s beliefs in their ability to cope with the initial trauma.

Psychological treatment of acute stress disorder

Cognitive behavioral approaches that include exposure.
Decreases the risk that ASD would develop in PTSD.