Report On Obsessive-Compulsive-Disorders-and-Trauma-related-Disorders

ARP: OCD & Trauma-Related Disorders
Applied Research Project Group 2: Obsessive-Compulsive Related and Trauma-Related

Disorders
Winona Marek, Francine Ranada, Keith Xavi Sazon
I. Definition of the Disorder
Obsessive-compulsive Disorder
According to the DSM-V, the diagnosis of obsessive-compulsive disorder is remarked
by the the presence of both obsessions and compulsions that are time-consuming (may take
up to 1 hour daily) and causes significant clinical distress or impairment among individuals in
social, occupational, or other important areas of functioning (American Psychiatric
Association, 2013). In addition, the obsessions and compulsions present in the individual are
not associated with physiological effects of a substance or medication and of another medical
condition.
Although most people may have experienced these tendencies, the obsessions and
compulsions of people diagnosed with OCD are severe and life-disrupting (Robbins et al.,
2019). In addition, these obsessions cause anxiety and distress in most individuals and may
also come in the form of images; as an attempt to either neutralize or suppress these
obsessions, individuals resort to engage in compulsions (Gillan et al., 2017).
Gillan et al., (2017) elaborates that the compulsions individuals engage in may not
necessarily be a realistic way to prevent what their fears centers on although these overt acts
are urge-driven. One sample association of an obsession with a compulsion is the fear of
contamination with which an individual responds by washing their hands (Robbins et al.,
2019) or engaging themselves in other hygienic practices.
Although the intrusive fear of contamination and compulsive hand washing are
among the most common and that they respond well to pharmacotherapy and psychotherapy,
these domains have become more prevalent with the emergence of the COVID-19 pandemic
(Banerjee, 2020). This is due to the fact that these domains have a tendency to relapse with
the occurrence of stress brought about by either external or environmental cues (Cordeiro et
al., 2015). These cues, such as the increased demand for hand washing and the continuous
release of information on the virus being able to stay on inanimate surfaces, possibly worsen
the symptoms of those diagnosed with OCD (Banerjee, 2020).
Body Dysmorphic Disorder

It is a shared and common experience for individuals to be conscious about their
appearance to a certain extent, but people diagnosed with Body Dysmorphic Disorder (BDD)
are distinguished by their “preoccupation with one or more imagined or exaggerated defects”
regarding their appearance, as characterized in the DSM-V. Other symptoms include the
performance of repetitive behaviors or mental acts as a response to appearance concerns, the
perceived defects of the individual are minimal or unobservable, and that the individual’s
preoccupation is not only limited to their weight and body fat concerns.
This disorder, classified along the obsessive-compulsive spectrum (Ramphul and
Mejias, 2018), compels individuals to engage in compulsive behaviors like those diagnosed
with OCD (Kring & Johnson, 2018). These compulsions that people with BDD have are
concerned with touching up their appearance; these are done in order to ease the distress
brought about by their intrusive thoughts. Some common behaviors include asking others for
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assurance, comparing their appearances to that of other people, and even attempting to
change their appearance or to conceal certain body parts or areas they dislike (Kring &
Johnson, 2018).
Hoarding Disorder
The need to acquire and keep items becomes excessive in the case of hoarding
disorder which is also characterized by having troubles in the discarding of possessions
(Kring & Johnson, 2018). This difficulty then leads to the disruption of an individual’s living
environment due to the perceived significance of such possessions. In addition, the living
conditions of an individual can result in functional impairment (Nordsletten, et al., 2013) and
can even become dangerous due to a significant amount of clutter (Mathes, et. al., 2020).
According to the classification of hoarding disorder in the DSM-V, an individual

would experience distress when faced with situations or efforts that concern parting with their
items or possessions. There is also a perceived need to save items and that the accumulated
amount of their possessions clutters their living spaces to a point where they become less
accessible for usage unless there is intervention from other people.
Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that occurs as a result of
witnessing traumatic events, although it does not necessarily have to be firsthand. Trauma
may happen even when learning of a loved one’s death or through repeated exposure to
aversive details of event/s. Unlike other disorders, much emphasis is placed in the cause of
PTSD. This may range from actual or threatened death, serious injury, or sexual violation
among others.
Apart from witnessing a traumatic event, diagnosis criteria of the DSM-V is based on
the following symptom clusters: intrusive symptoms (e.g. memories, dreams, flashbacks),
internal and/or external avoidance of reminders, negative alterations in cognitions and mood
(e.g. self-blame heavy expectations, diminished interest, etc.), and changes in arousal and
reactivity (hyperactivity, loss of attention, aggression, etc.). These symptoms must have
worsened after the traumatic event and must have persisted for more than 1 month. Diagnosis
for children under 7 years of age is largely similar but they may not exhibit either avoidance
symptoms or negative alterations in mood/cognition (Kring & Johnson, 2018).
These symptoms may not manifest right after the traumatic event. In fact, some
people may try to convince themselves that they are doing fine until they notice severe
impairment of their function in daily tasks such as school or work. Unfortunately, the severity
of these symptoms are also notably worsened by comorbidity which may develop before or
after the traumatic event. Examples of these are substance abuse, mood and anxiety disorders,
impulsive or dangerous behaviour or self-harm (Yehuda et al., 2015).
Acute Stress Disorder

Acute Stress Disorder (ASD) is a disabling psychological condition that can occur
after exposure to trauma (American Psychiatric Association, 2020). Some traumatic events
include, but are not limited to, exposure to war, sexual violence, and natural or
human-induced disasters. Like PTSD, it is characterized by similar symptoms, including
intrusive thoughts and memories, negative mood, avoidance, and hyperarousal. For instance,
a person with ASD might experience intrusive thoughts and dreams related to the traumatic
event. Dissociation, described as an altered sense of the reality of one’s surroundings or
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oneself, is another symptom of ASD. People with ASD might experience feeling dazed or as
if they were in another person’s body (American Psychiatric Association, 2013). In
comparison to PTSD, the duration of the symptoms for ASD is shorter. Symptoms of ASD
are expected to occur for at least three days and no longer than one month after trauma. If the
symptoms exceed a month, it may progress to PTSD (American Psychiatric Association,
2013).
II. Statistics or Epidemiology
Obsessive Compulsive Disorder

In Singapore, the prevalence of both lifetime and 12-month OCD was examined by
using the data obtained in the Singapore Mental Health Study 2016. The lifetime prevalence
of OCD was 3.6% whereas the 12-month prevalence was 2.9% (Subramaniam et al., 2020). It
was also found in the same study that those diagnosed with OCD had higher odds of major
depressive disorder, bipolar disorder, generalized anxiety disorder, and alcohol abuse.
Additionally, suicidal ideation and suicidality was significantly associated with OCD.
It has been estimated that 50% of the individuals who are diagnosed with OCD have
had their symptoms emerge in childhood and adolescence (Goodman et al., 2014) with 19.5
years old being the average age of onset (Fenske & Petersen, 2015). Additionally, it is
uncommon for people aged over 40 to have OCD initially present (Goodman et al., 2014).
Females are also more affected compared to males even if the latter would usually have an
earlier onset of symptoms. It must be noted that females who are postpartum are up to twice
as likely to develop OCD in comparison with the general female population.
Interestingly, with the COVID 19 pandemic, prevalence of OCD is at 17.93% just

three months after the quarantine in Wuhan. 89% of individuals both had obsessions and
compulsions meanwhile 8% had only obsessions and 3% had only compulsions (Zheng et al.,
2020). Another study by Khosravani et al., (2020) discovered that patients with OCD scored
higher during the pandemic on all OC symptom dimensions and symptom severity, not just
those related to hygiene.
The only data in the Philippines that is somewhat related is a study conducted by
Arcamo et al. (2015). In the areas of Bohol and Siquijor, 33% of the 26 respondents that
participated accounted for obsessive compulsive personality disorder (OCPD). However, it is
important to note that obsessive compulsive disorder is not the same as obsessive compulsive
personality disorder. The symptoms that patients with OCD experience causes distress which
is a contrast to patients with OCPD not finding an issue with said symptoms. Currently, it
could be said that OCD is understudied in the Philippine context given the scarce availability
of research studies.
Body Dysmorphic Disorder

The estimated prevalence of body dysmorphic disorder is 1.9 % in the community and
5.9% in adult outpatient psychiatric settings meanwhile it is around 7.4% in adult inpatient
psychiatric settings (Singh & Veale, 2019). According to Veale et al., (2016) in the majority
of the settings, there was a higher prevalence among women except in those that are cosmetic
and dermatological.
Mufaeddal et al. (2013) states that there exists a considerable overlap between body
dysmorphic disorders and other psychiatric disorders such as OCD, anxiety and delusional
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disorder.; there is a co-occurence of BDD with pathological skin picking, which is a repetitive
behavior, in 26%-45% cases. Additionally, body dysmorphic disorder has a high level of
comorbidity with depression and social phobia with an occurence of >70% in patients with
BDD. The estimated percentage of dermatologic patients having BDD falls within 9%-14%
considering that individuals who are diagnosed with body dysmorphic disorder frequently go
to dermatologists.
Hoarding Disorder
The prevalence of hoarding disorder is currently surrounded with uncertainty as a
result of issues in the methodology in the evidence base, Postlethwaite et al., (2019)
elaborates that the percentage for prevalence varies widely from 1.5% to 6% of the general
population. However, the pooled estimated prevalence for hoarding disorder in the study was
2.5% and that the prevalence rates for both males and females did not differ much from each
other through subgroup analyses. In contrast to this, a study dated earlier by Samuels et al.
(2007) found that the prevalence of hoarding in community samples was nearly 4% and was
less common in younger age groups in comparison to older age groups.
In terms of comorbidities, less than 20% of people with hoarding disorder meet the
criteria for OCD, Men had a higher rate of obsessive compulsive disorder in hoarding
disorder as compared to women. Social phobia was also more prevalent among men with
hoarding disorder than those with OCD. 28% of the participants with hoarding disorder in
disorder were also diagnosed with inattentive HD and this diagnosis was more frequent to be
found than participants with OCD (3%). Similarly, high rates were detected for both major
depressive disorder (MDD) and acquisition-related control disorders such as compulsive
buying, kleptomania, and obtaining free items; the said rates were also higher in participants
with hoarding disorder than those with OCD (Frost et al., 2015)
Alcohol dependence; paranoid schizotypal, avoidant and obsessive compulsive

personality disorder traits; insecurity from home break-ins and excessive physical discipline
at a minor age; and parental psychopathology were all associated with hoarding (Samuels et
al., 2007).

In the DSM 5, the projected lifetime risk for PTSD in the United States is estimated to
be 8.7% at age 75; the 12-month prevalence as well among adults is around 3.5%. The
lifetime prevalence of PTSD was higher in women with 9.7% as opposed to the 3.6
percentage among men. To add to this, PTSD occurs more frequently for women who have
been sexually assaulted with the lifetime prevalence at 50% (Chivers-Wilson, 2006). Having
said this, the most common cause of the occurrence of PTSD in women is sexual assault, a
study has reported that during the first two weeks after an assault took place, 94% of the
women experienced PTSD symtpoms (Chivers-Wilson, 2006).
The conditional probability of developing PTSD may vary across cultural groups even
if distinct groups have different levels of exposure to traumatic events. Veterans and other
individuals such as police, firefighters, and emergency medical personnel whose professions
or occupations involve a higher risk of traumatic exposure have higher prevalence rates of
PTSD. Survivors of rape, military combat and captivity, and “ethnically or politically
motivated internment and genocide” make up for the highest rates in PTSD (American
Psychiatric Association, 2013).
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In children and adolescents, the prevalence rates of PTSD are lower following an
exposure to a traumatic event, however, this may be due to the fact that the previous criteria
used may not have taken into account the developmental aspect of this condition. Considering
that the full time prevalence of PTSD is lower in older adults, there is evidence that asserts
that subthreshold presentations of PTSD are more common in later life; the symptoms
experienced are associated with other substantial clinical conditions (American Psychiatric
Association, 2013).
Flory and Yehuda (2015) states that approximately half of the people who are
diagnosed with PTSD also suffer from major depressive disorder, which was proven in
diverse epidemiological samples (Breslau et al., 1997; Rytwinski et al., 2013). Greater social,
cognitive, and occupational impairment is observed in people with both PTSD and MDD,
these indiviuals also reported higher levels of distress and are more likely to attempt suicide.
Anxiety and depression, on the other hand, significantly co-occurred with PTSD in Korean
war veterans where all three disorders were strongly associated with heavy combat and low
rank (Ikin et al., 2007).
Although there are currently no extensive studies or statistics on the national level for
PTSD, certain studies have tackled PTSD within a particular setting with PTSD cases that
arose amid national disasters such as Typhoon Yolanda. Howard et al., (1999) conducted a
mental health survey that consisted of 351 tribal and non-tribal victims of the Mount Pinatubo
disaster after they have been displaced for six years. The initial results of this study presented
that posttraumatic stress disorder (26.7%) and major depression (14.0%) were the two most
common diagnoses.
Acute Stress Disorder

According to the DSM V, the prevalence of ASD varies depending on the nature of
the event and the context in which it is assessed in populations that were recently exposed to
trauma. There are higher prevalence rates of ASD ranging from 20% to 50% among
interpersonal traumatic events which include assault, rape, and witnessing a mass shooting;
ASD also tends to be identified in traumatic events that do not involve interpersonal assault at
a percentage of less than 20. Motor vehicle accidents (13% to 21%), mild traumatic brain
injury (14%), assault (19%), severe burns (10%), and industrial accidents (6%-12%) are
among the events where interpersonal assault is not involved.
Fanai & Khan (2021) elaborates on the epidemiology of ASD by citing several
studies; a pooled prevalence of 15.81% for ASD among road traffic accidents was obtained in
a meta-analysis performed by Wenjie Dai et al (2018). On the other hand, the prevalence for
ASD was 14.2 % in two weeks for emergency room encounters among children aged from
7-17 years who were exposed to trauma; at nine weeks the prevalence rate of PTSD was at
9.6% (Meiser-Stedman et al., 2017). Meanwhile Helle et al. (2018) conducted a postpartum
cross-sectional study where it showed that mothers who gave birth to preterm infants had
significantly higher rates of ASD (14.9%) than those who gave birth to term basis (0%).
III. The Illustrative Case Studies
OCD-Related Disorders
The etiology of OCD-Related disorders is best explained as an interplay of genetic
risk, neurological functioning, and cognitive-behavioral patterns.
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Genetic Risks of OCD-Related Disorders

Several studies have shown that heritability accounts for 40-50% of the variance of
OCD-related disorders (i.e. OCD, BDD, Hoarding Disorder) with non-shared environmental
factors along with errors comprising the majority of rest (Monzani et al., 2014).
For OCD, controlled family studies show that risk increases proportionally to the
degree of relatedness, that is, first-degree relatives such as parents, children, or siblings were
more likely to develop the condition (Bienvenu et al., 2012). Twin studies support this
finding without notable influence from a shared environment (Kendler et al., 2008).
Similarly, model fitting analyses show that over-concern with one’s physical appearance is
heritable, increasing the risk of BDD and other related disorders. Nonshared environmental
factors are acknowledged to be significant in its etiology but shared environment is not
(Monzani et al., 2011). These results are similar to twin studies on compulsive hoarding but
with higher prevalence and heritability in women (Iervolina et al., 2019).
In the case of Karen, her mother exhibited high conscientiousness for rituals but apart
from that, she is not closely related with someone diagnosed with OCD-related disorders.
However, it is important to keep in mind that her condition is a notable genetic risk of her
children. It is also concerning that her daughters are often teasing each other’s weight. Her
eldest who is mildly obese, is noted to show relatively more distress as she is often to object
of ridicule. Taking the diathesis-stress paradigm into application, this kind of environment
can be a crucial factor for Karen’s daughters to develop OCD-related disorders given their
genetic predisposition.
Neurological Risks of OCD-Related Disorders

There have also been significant advances in research as to which brain structures and
brain connections are affected when a person with an OCD-related disorder experiences
distress related to the disorder. All three disorders share signs of increased activities in the
fronto-striatal circuit, particularly the orbitofrontal cortex, caudate nucleus, and anterior
cingulate (McGuire, Bench, et al., 1994; Feusner et al., 2010; Tolin et al., 2009).
When those with OCD are presented with triggers, not only is the fronto-striatal
circuit activated but its functional connectivity is also altered (McGuire, Bench, et al., 1994).
Those with BDD, on the other hand, are noticed to exhibit orbitofrontal cortex and caudate
nucleus hyperactivity when given the chance to observe themselves (Feusner et al., 2010).
Finally, those with Hoarding Disorder experience increased activity in the orbitofrontal cortex
(Tolin et al., 2009) and the anterior cingulate (Tolin et al., 2012) when asked to sort or discard
their possessions.
Given this neurological explanation, Karen’s anxiety when faced with her obsession
for safety, can be traced to increased activity of the fronto-striatal circuit and a change in the
functional connection between the orbitofrontal cortex, caudate nucleus, and anterior
cingulate. Her counting compulsion then helps regulate the hyperactivity, even when the
trigger (e.g. items that can be counted) is not necessarily a threat as she thinks it is. With
proper treatment, the hyperactivity of the orbitofrontal cortex and caudate nucleus can be
addressed, consequently reducing OCD symptoms (Ahmari & Dougherty, 2015).
Learning Theories of OCD

Mowrer’s Two-stage theory serves as the principal conditioning Model of OCD
(Storch et al., 2007). The first stage involves a pairing of a neutral and an aversive stimulus.
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Through association, the person develops fear of certain situations. The second stage uses
Operant conditioning as an explanation for the persistence of compulsive rituals of
OCD-related disorders as a result of negative reinforcement. The short-term relief from
distress that people experience is rewarding, even if it is harmful in the long-term.
In Karen’s case, the first stage of Mowrer’s theory is most notably established when
she witnessed an infant get run over. As someone who was pregnant at that time, it is
understandable how she later developed an obsession for her children’s safety although it is
not clear which neutral stimuli was paired with this aversive incident. This is consistent as
she does not have any specific environmental trigger. On the other hand, her compulsive
counting relieves her of distress, therefore, sustaining the symptoms.
Cognitive Model of OCD

There are also explanations on cognitive aspects alone such as Thought Suppression
Model of Obsessions. Most people with OCD have a type of belief called thought-action
fusion wherein they are either convinced that thinking about something is just as bad as doing
it or thinking about something makes the event more likely to happen (Rassin et al., 2001).
This kind of belief makes the obsessive thoughts distressing but the only way they know how
to deal with it is through Thought Suppression. Although Thought Suppression does not
exactly account for the cause of obsessive thoughts, it emphasizes that the person’s response
or attempt to suppress it is what makes the condition worse (Rassin et al., 2001).
Given what was mentioned in the case study, it is unclear to what extent Karen
exhibited thought suppression and thought-action fusion, especially since she is noted to
resort to compulsions right away. However, this model is a viable explanation of her
cognitive processes whenever her obsessions get triggered.
Cognitive Etiology of BDD

While BDD shares genetic and neurological risks with OCD, it has its own set of
explanations on the cognitive process of people diagnosed with it. It is important to note that
people with BDD typically do not have distorted physical images of themselves. Instead, they
are usually detail oriented, especially when it comes to facial features. This means that they
focus their attention on individual features and, consequently, flaws of their physical
appearance, even if those are not noticeable should a person look at them as a whole (Feusner
et al., 2010; Lambrou, Veale, & Wilson, 2011). On top of this, they also overvalue
attractiveness upon which they attribute their self-worth, amplifying rumination and
alterations of mood (Veale, 2004).
Cognitive-Behavioral Etiology of Hoarding Disorder

For an evolutionary perspective, Hoarding Disorder is believed to originate from an
adaptive response to the scarcity of resources such as food that our ancestors had (Zohar &
Felz, 2001). Today, Cognitive-Behavioral models seek to identify various factors that may
make this adaptive response uncontrollable. The most common factors are poor cognitive
organizational abilities, unusual beliefs about possessions, and avoidance behaviors (Timpano
et al., 2016).
People with Hoarding Disorder have problems focusing their attention (Tolin &
Villavicencio, 2011). Likewise, laboratory studies show that they often have difficulty
generating categories, often finding it anxiety-provoking (Wincze, Steketee, & Frost, 2007).
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On top of this, those with Hoarding Disorder have dysfunctional beliefs and extreme
emotional attachment to their possessions, to the extent of treating them as core to their own
identity. This manifests in their sense of responsibility to take care of these items as well as
extreme feelings of grief when parting them (Timpano et al., 2016).
People with Hoarding Disorder may then resort to avoidant behaviors, which is
negatively reinforced by the removal of the anxiety that comes along with discarding and
sorting items. This means that avoidance encourages them to continue hoarding rather than
confronting the need to discard and sort items.
Trauma-related Disorders
Not all people who experience trauma will develop trauma-related disorders. Several
risk factors, which often overlap, contribute to the development of PTSD symptoms, such as
genetic vulnerability, amygdala hyperactivity, diminished activity of the prefrontal cortex,
childhood trauma exposure, and reactivity to threat. (American Psychiatric Association,
2013; Kring & Johnson, 2018).
Genetic Risks
An increasing body of evidence from diverse research designs has shown that genetics
influence the development of PTSD (Nugent et al., 2008). In a family study about Holocaust
survivors, results indicated that people who have relatives with PTSD are at a greater risk of
developing the disorder (Yehuda et al., 2001). In line with this, twin studies discovered that
genetic factors accounted for a moderate amount of the variance in the individual PTSD
symptoms (True et al., 1993, as cited in Afifi et al., 2010).
Twin studies also suggest that that genetic influences on PTSD overlap with those for
other mental disorders, such as anxiety disorders and major depressive disorders
(Chantarujkapong et al., 2001; Fu et al., 2007; Koenen et al., 2008; Scherrer et al., 2008; Xian
et al., 2000 as cited in Afifi et al., 2010; Tambs, Czajkowsky, et al., 2009 as cited in Kring &
Johnson, 2018). For instance, a twin study on generalized anxiety disorder symptoms, panic
disorder symptoms, and posttraumatic stress disorder in men demonstrated that genetic
influences common to anxiety disorder symptoms accounted for over 60% of the genetic
variance in PTSD (Chantarujikapong et al., 2001).
Knowing that PTSD appears related to genetic risk for mood and anxiety disorders,
there is a possibility that genetic risk factors propelled the onset of her PTSD symptoms.
Jocelyn displayed anxiety disorder and depression symptoms, such as recurrent and intrusive
images, avoidance, hypervigilance, and startle responses. However, it is important to note that
the symptoms between PTSD and other disorder groups overlap, and the research on genetics
role in PTSD is limited.
Neurobiological factors
Many symptoms of PTSD are linked to the dysregulation and dysfunction of
processes involving emotion regulation. Several studies have shown that people with
symptoms of PTSD displayed heightened amygdala activation, which can cause exaggerated
fear responses, assessment of threat-related stimuli, and memory consolidation. People with
PTSD also revealed decreased activation of regions in the medial prefrontal cortex, which can
interfere with processing emotions and regulating emotions (Pitman et al., 2016).
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Aside from this, other bodies of information discovered that chronic exposure to
stress could damage and shrink the hippocampus (Kim et al., 2015). Research also suggests
that people with PTSD displayed greater hippocampal activation during cognitive tasks than
those without PTSD (Kring & Johnson, 2018). Damage to the brain region could result in
memory-related problems and difficulties recovering from traumatic experiences.
This neurological perspective explains Jocelyn’s symptoms as a result of exaggerated

amygdala activation, deficient activation in her medial prefrontal cortex, and greater
hippocampus activation. For instance, her heightened fear responses towards non-threatening
stimuli can be attributed to exaggerated amygdala activation. She mentioned that she was
often hypervigilant and was easily startled by some of her friends’ friendly gestures. Even in
safe spaces, she felt immense fear. This can be a sign of her hippocampus’s heightened
activity. Jocelyn also exhibited problems in regulating her emotions. There were times when
her roommates found her crying at unexpected times. She also shared that she would fight
with her boyfriend. These events can be attributed to the decreased activation of regions in
the medial prefrontal cortex.
Pretraumatic environmental factors

Under environmental factors, the DSM 5 suggests that prior traumatic exposure can
contribute to the development of PTSD symptoms. In a therapy session, Jocelyn shared that
she was sexually assaulted at a music summer camp at 13 years old. Although the event
caused her great discomfort, she did not seek psychological aid. She also shared that her
boyfriend in high school would pressure her to engage in sexual acts, even if she felt
uninterested or uncomfortable. Given this, her prior experiences with trauma made her more
at risk for PTSD.
Severity and Nature of Trauma

The severity of trauma can determine whether or not a person will develop PTSD
(Kring & Johnson, 2019). The DSM V states that people who experience a greater magnitude
of trauma are more likely to develop PTSD (American Psychiatric Association, 2013).
Additionally, several traumatic experiences confer high risks to developing PTSD, such as
rape and direct combat (Yehuda et al., 2015). In Jocelyn’s case, she was raped by her English
assistant teacher. In the situation, she felt immense fear and distress, as her life was
threatened. Because rape ranks high in severity, victims of sexual assault are more at risk of
developing symptoms. For Jocelyn, it was evident through her thoughts and behavior that she
developed symptoms of PTSD.
Another contributing factor in the development of PTSD symptoms is the nature of

the trauma. Research has shown that human-induced traumas were more likely to cause
PTSD than natural disasters (Charuvastra & Cloitre, 2008, as cited in Kring & Johnson,
2019). Specifically, people who experience traumatic events such as rape, combat experience,
abuse, and assault are at higher risk of developing symptoms of PTSD (McMillan &
Asmundson, 2016 as cited in Kring & Johnson, 2019). For Jocelyn, the perpetrator was
somebody she knew and trusted. Because she thought that she could trust him, she began
developing tendencies of guilt and self-blame.
Learning Theories of PTSD

Mowrer’s Two-Factor model and other behavioral theories suggest that some
symptoms of PTSD are developed and maintained by classical conditioning (Antony & Stein,
2009; Kring & Johnson, 2019). With this, classical conditioning can be attributed to Jocelyn’s
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case. The traumatic event, in Jocelyn’s case, the rape incident, acts as the unconditioned
stimulus. The event elicited an unconditioned response which was immense fear and anxiety.
Factors such as cognitive, environmental, and emotional related stimuli are considered as the
conditioned stimulus. Because these related stimuli are associated with the traumatic
experience, they can evoke a similar response. As such, the more related the conditioned
stimulus is to the traumatic event, the stronger the conditioned response (Antony & Stein,
2009). For Jocelyn, this is seen when she had a heightened startle response when she was
unexpectedly tapped on the shoulder from behind. Jocelyn mentioned that on the night of the
rape, the teaching assistant attacked her from behind. Given this, Jocelyn’s heightened
response can be attributed to the shared element of surprise in getting attacked from behind
and getting tapped on the shoulder unexpectedly.
Operant conditioning can also contribute to the maintenance of avoidance behavior

(Kring & Johnson, 2019). To avoid feelings of fear and distress, Jocelyn avoids objects,
people, and thoughts that remind her of the traumatic event. For instance, after she was raped,
she decided not to tell anyone. She also shared that she avoided nightmares similar to the
traumatic event by staying up at night. Another avoidance behavior she exhibited was her
inability to walk alone in the dark to the library, which reminded her of the night she was
raped. Perhaps, to Jocelyn, recalling the traumatic experience evoked overwhelming feelings
of distress and fear. As such, she would do what she could to avoid reliving the experience to
some degree.
In relation, Jocelyn reported feeling dissociated from herself. For instance, Jocelyn
shared in a therapy session that she had difficulty identifying herself when she passed by a
mirror. Jocelyn’s dissociative behavior can also be linked to conditioning. Dissociative
behavior enables a person to avoid confronting memories of the traumatic event. For Jocelyn,
dissociation became a coping mechanism that allowed her to avoid facing the trauma, which
could have contributed to the rapid onset of her symptoms. However, as seen in Jocelyn’s
case, avoidance and dissociative behaviors exacerbated her symptoms and made it difficult
for her to extinguish fear.
Protective factors
Although findings are limited, social support is considered a potential protective
factor in the development, maintenance, and treatment of PTSD (American Psychiatric
Association, 2013; Gros et al., 2016; Kring & Johnson, 2019). In a study about the relations
between social support, PTSD symptoms, and substance use in war veterans, results showed
that increased social support was associated with less severe PTSD symptoms (Gros et al.,
2016). However, in Jocelyn's case, her boyfriend and roommates' reactions to her situation
posed more problems for her, making her feel even more alone. Jocelyn's situation shows that
social support may not always be effective. Additionally, having a social support network is
not enough to treat symptoms (Oltmanns et al., 2012). Perhaps, if Jocelyn's friends treated her
in a supportive and meaningful manner, she would have coped better with her symptoms.
IV. Diagnostic Impression
Obsessive-Compulsive Disorder
Diagnostic Impression
Under Axis I: Clinical Disorders, Karen falls under Obsessive Compulsive Disorder
with both obsessions and compulsions present given the DSM-5 criteria.
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Karen reports to often experience intrusive thoughts regarding accidents happening to

her Children (Obsession Criterion A1). Unfortunately, these thoughts were more often than
not confirmed as her children would often find themselves in minor accidents every now and
then. Attempts to suppress these thoughts are present but to no avail as she finds the anxiety
too much to handle (Obsession Criterion B1).
Karen has also developed a compulsive ritual for counting items or activities. These
rituals, although unrelated to accidents, are deemed necessary by Karen to be executed with
precision for fear of causing harm to her children (Compulsion Criterion A1, B1, C1). During
times when she would “fail” to do so, she reported feelings of dread and apprehension
(Compulsion Criterion D1). In the last few months before seeking treatment, she reported
intense feelings of distress from not being able to control these behaviors.
In addition to these, Karen also feels the need to follow home and church rules
faithfully. She even reported feelings of distress when the church decided to change the
language of the mass (Compulsion Criterion B1, D1).
Under Axis II: Developmental Disorders and Personality Disorders, Karen does not
exhibit any symptoms although her social skills are notably underdeveloped.
Under Axis III: General Medical Conditions, Karen does not exhibit any symptoms.
Under Axis IV: Psychosocial and Environmental Problems, Karen’s stressful married
life has the most significant influence on her distress. Her husband does not help out with
chores and her children are difficult to manage. The latter are also frequently involved in
minor accidents, making Karen’s obsession for their safety worse.
In addition, changes in church rituals is an additional source of distress for her.
Under Axis V: Global Assessment of Functioning Scale, Karen gets a score of 62.
Although she is often in distress, she is still able to do most of the family chores and errands
for six people. This, of course, does not mean she manages it well but it is indicative of her
capability to continue with her tasks. Her social functioning, particularly in her family, is
visibly affected but it is largely because the environment makes it difficult for her.
Figure I. Diagnostic Impression Summary: OCD.

Axis I Obsessive Compulsive Disorder
Axis II None
Axis III None
Axis IV Stressful family environment; Changing church rituals
Axis V 62: Moderate symptoms; Moderate difficulty in social

occupational or social functioning
PSYC 26 11
Treatment
As disturbing Karen’s obsessions and compulsions are for her, it is clear that there is
more to address than just that. Her compulsions have led to her having difficulty asserting
herself to her husband as well as managing her children. These have significantly affected her
quality of life. For this reason, her therapist considered ERP as the final treatment strategy
once Karen is able to equip herself with skills that allow her to almost immediately have
genuine control over her family situation.
Their first sessions focused on assertiveness training. Through a daily journal, they
were able to properly assess scenarios herein she was unable to assert herself. She and her
therapist then role-played incidents so that she can get used to more appropriate responses
and confrontations instead relying on passive-aggressive behaviors. In addition, her fears of
being unloved should she use assertive behaviors were also discussed. Once the assertion
training yielded positive results, she and her therapist then discussed effective
child-management skills through operant conditioning. So instead of reinforcing negative
behaviors, she was trained how to properly ignore quarrels and encourage play-time amongst
her children.
Apart from skills-training, Karen and her therapist also addressed her concerns about
religion. However, instead of discussing it between them, she was encouraged to seek priests
who align with her conservative views for an educational discussion on why church rituals,
particularly its delivery in Latin, are changed. Hearing those reasons from them allowed her
to have a renewed interest in church activities with less intrusive anxiety over rituals.
Finally, after being equipped with skills and knowledge that can more immediately
improve her quality of life, Karen underwent Exposure and Response Prevention (ERP). This
treatment was developed to specifically address compulsive rituals through direct or implicit
exposure to stimuli that evoke anxiety. In Karen’s case this manifests in compulsive counting
whenever choosing items or doing certain activities. By gradually exposing her to different
stimuli she is used to (e.g. grocery items, cigarette, coffee cups) while resisting a compulsive
response and seeing out the anxious feelings, the cycle of obsession and compulsion is
gradually broken.
Although ERP is the gold-standard for OCD treatment, it is still possible for Karen to
experience a relapse in her OCD symptoms. Should it happen, it is recommended to undergo
“third-wave” Cognitive-Behavioral Therapy instead of repeating the ERP. Although relatively
new, this new approach to CBT places mindfulness as a core feature of the treatment,
modifying Karen’s relationship with her thoughts and feelings instead of deliberately
changing it (Manjula & Sudhir, 2019). The active acceptance of psychological discomfort
will reduce her distress without necessarily undergoing anxiety-provoking procedures such as
those in ERP.
Still, whether or not Karen would need to undergo another treatment, it is highly
recommended to engage in mindfulness practices that can help her manage negative thoughts
and feelings before they become too much to handle. Breathing exercises, body scans, and
even mindful walking or eating align with the goals of third wave CBT, should treatment be
unnecessary.
PSYC 26 12
Under Axis I: Clinical Disorders, Jocelyn falls under Posttraumatic Stress Disorder
with several symptoms present given the DSM-5 criteria. Under Criteria A, Jocelyn
experienced rape, which is a form of sexual violence. She reported having recurrent,
involuntary, and intrusive recollections of the incident (Criterion B1). When reading her
English book, Jocelyn would experience intrusive images of her being physically assaulted.
She also experienced nightmares about unfamiliar men in dark clothing attempting to hurt
her, causing her great distress (Criteria B2).
Jocelyn also displayed avoidance symptoms. She made deliberate efforts to stop
intrusive recollections about the incident to the point that it affected her concentration. She
also stayed up at night to prevent nightmares from occurring (Criteria C1). Additionally, she
no longer attended her English course, as the thought of the teaching assistant evoked
feelings of fear (Criteria C2).
She also displayed persistent and exaggerated negative expectations towards the
people around her and herself. In a therapy session, she expressed that she did not feel safe
walking with anyone in the dark. In another session, Jocelyn explained that she did not want
to open about the incident to her friends, campus police, and English professor as she thought
they would not believe her. (Criterion D2). Jocelyn also exhibited erroneous cognitions about
the cause of the rape, thinking that she might have worn a provocative outfit or seemed
sexually inviting (Criteria D3). She often felt guilty and tended to engage in self-blame
(Criterion D4). Given these negative cognitions towards herself and others Criterion D5).
Another symptom she displayed is heightened startle response to unexpected

movements. As mentioned, she was easily startled whenever she was tapped on the shoulder
unexpectedly (Criterion E4). Because of her lack of sleep, coupled with intrusive thoughts
and memories, Jocelyn found it difficult to concentrate on her studies, which affected her
academic performance (Criterion E5). She also experienced nightmares related to the
traumatic incident, which interfered with getting adequate sleep (Criterion E6). She also
reported feeling detached and dissociated from herself.
Under Axis II: Developmental Disorders and Personality Disorders, Jocelyn does not
exhibit personality disorders and mental retardation symptoms.
Under Axis III: General Medical Conditions, Jocelyn does not exhibit any symptoms.
There was no mention of any medical conditions that might have affected the development of
Jocelyn’s PTSD symptoms.
Under Axis IV: Psychosocial and Environmental Problems, Jocelyn experienced some
environmental triggers. Activities that reminded her of the trauma, such as reading, triggered
Jocelyn’s intrusive thoughts and evoked fear and distress. Similarly, nightmares also evoked
immense fear from Jocelyn, making her lack sleep. Unexpected actions, such as shoulder taps
from behind, frighten Jocelyn and cause a reactive response, which has offended some of her
friends.
Jocelyn had problems with her social environment. When she opened about the sexual
assault, her boyfriend and roommates were unsupportive. Her roommates either accused her
of lying about the situation or downplayed the trauma. Her boyfriend’s response was to break
up with her. He was very upset from what he heard and decided to cope with his feelings
PSYC 26 13
about her trauma. Despite Jocelyn’s request not to tell anyone about the incident, her
boyfriend told his friends, sparking gossip in their community. As such, Jocelyn did not
receive adequate support from her loved ones and friends.
Under Axis V: Global Assessment of Functioning Scale, Jocelyn gets a score of 55.
The score falls under the fifth range of 60-51, which states moderate symptoms (e.g.,
intrusive recollections and heightened startle response). Jocelyn also displayed difficulty in
social occupational functioning and social functioning. Because of her symptoms, she had
trouble in school, which made her academic performance decline drastically. In addition, she
was unable to properly manage her relationships with her boyfriend, friends, and roommates.
Figure II. Diagnostic Impression Summary:PTSD.

Axis I Posttraumatic stress disorder
Axis II None
Axis III None
Axis IV Break-up with boyfriend and absence of meaningful support from

her friends
Axis V 55: Moderate symptoms or moderate difficulty in social,

occupation, or school functioning
Treatment
The treatment for PTSD can either be medical, psychological, or a combination of
both. Medical treatment includes taking antidepressants, such as Selective Serotonin
Reuptake Inhibitors (SSRI) or Serotonin-Norepinephrine Reuptake Inhibitors (SNRI).
Psychological treatments involve exposure treatment, cognitive therapy, and short-term
treatment of ASD.
The first few sessions of therapy were focused on providing Jocelyn a safe space to
express her feelings. When she opened up about getting raped by a teaching assistant to her
boyfriend and roommates, they did not offer any meaningful support. Instead, their
interactions exacerbated her situation and made her feel more alone. Having a safe space to
express her frustrations and anger enables her to emotionally-processes her situation. It can
also aid her in learning how to trust people again.
Medication
Exposure to chronic stress and high-intensity traumas can affect several functions of
the brain. These events can have long-lasting effects on the brain and behavior and stimulate
the brain’s fight-or-flight response even in safe environments (Voss & Temple, 2007). As
people with PTSD experience high levels of stress, they may opt to take medications such as
Selective Serotonin Reuptake Inhibitors (SSRI) or Serotonin-Norepinephrine Reuptake
Inhibitors (SNRI) to improve their symptoms. In Jocelyn’s case, she reported experiences of
heightened arousal, avoidance of stimuli related to the trauma, and intrusive recollections of
the trauma. For instance, she would get easily startled by an unexpected tap on the shoulder.
PSYC 26 14
She also reported re-experiencing the trauma whenever she encountered stimuli that
reminded her of the trauma, such as walking in a dark alley or reading her English book. In
conjunction with psychological treatment, taking medication can alleviate her symptoms and
improve her mood, anxiety, and other bodily functions.
However, it is important to note that people respond differently towards medication.

Several side-effects from taking antidepressants include insomnia, diarrhea, and loss of
appetite (Alexander, 2012). As such, medications must be tailored to the person’s needs.
Additionally, a person is expected to relapse if medications are discontinued (Kring &
Johnson, 2019). Should Jocelyn opt for medical treatment, they must monitor her response to
the medication and ensure that she takes them on time.
Exposure treatment
Exposure treatment, a cognitive behavioral therapy, is the primary psychological
approach to treating PTSD (Kring & Johnson, 2019). It was discovered that exposure
treatment alleviated symptoms of PTSD far better than medication, supportive unstructured
psychotherapy, or relaxation therapy (Powers, Halpern, et al., 2010; Taylor, Thordarson, et
al., 2003, as cited in Kring & Johnson, 2019). Exposure treatment aims to gradually decrease
the emotional intensity associated with the memory of the event and challenge the belief that
the person cannot cope, with its benefits lasting for over five years (American Psychological
Association, n.d.; Kring & Johnson, 2019).
There are several variations of exposure treatment, such as imaginal exposure, in vivo
exposure, and virtual reality exposure. A strategy that seems fitting for Jocelyn’s case is
imaginal exposure therapy. Should Jocelyn engage in this treatment, she will be asked to face
the fears associated with the rape and recall and describe the traumatic event to reduce her
feelings of fear. She will be working through an exposure hierarchy from less intense fears to
more severe ones. In her case, this might involve walking alone or narrating the traumatic
event to her therapist.
The treatment can address several symptoms in several ways. By re-experiencing the
traumatic event in a safe space, Jocelyn’s fear of actions, people, objects, or situations related
to trauma can decrease over time. Exposure therapy can also help Jocelyn develop
self-efficacy, that she is capable of confronting her fears and managing her emotions.
Additionally, the treatment can also help with emotional processing. For Jocelyn’s case, she
can learn to attach new, more realistic beliefs about her traumatic experience. For example,
she can learn not to blame herself and feel less guilty in the process. Additionally, it might
help her relearn certain behaviors that affect other people, such as her heightened startle
response.
Cognitive therapy
Another approach to treating PTSD is Cognitive Therapy, which can supplement
exposure treatment (Kring & Johnson, 2019; Oltmanns et al., 2012). Cognitive therapy aims
to address maladaptive ways of perceiving events in the person's environment and change
overly negative assumptions and beliefs that lead to negative emotions (Ehlers & Clark,
2008; Oltmanns et al., 2012).
Several types of cognitive-behavioral therapy can treat symptoms of PTSD. Cognitive

Processing Therapy (CPT) is a strongly recommended treatment for PTSD as it has been
effective in treating symptoms (American Psychological Association, 2017). CPT helps
PSYC 26 15
clients modify and unhelpful beliefs related to the trauma, enabling them to create a more
healthy understanding and conceptualization of the traumatic event; This can reduce the
clients' tendencies towards self-blame and guilt (American Psychological Association, n.d.;
Kring & Johnson, 2019).
For Jocelyn's case, CPT can help her overcome her guilt and tendency to blame
herself for what happened. In a therapy session, she shared that she felt that she did not fight
her perpetrator hard enough and could have acted provocatively. Engaging in CPT can enable
her to reframe her thoughts about the traumatic rape, reducing the guilt, fear, and negative
thoughts she has towards herself.
V. Recommendations:
Theoretical recommendations/Practical or Applied recommendations
OCD-Related disorders
Evidence shows that ERP yields the most consistent results for people with OCD
(Twohig et al., 2010). However, that does not mean that medication is not an effective
supplement. Recent studies show that prolonged use of selective serotonin reuptake inhibitors
(SSRIs) has the highest efficacy in reducing OCD symptoms and is even higher when paired
with ERP (Casale et al., 2019).
ERP is also widely used for clients with BDD and Hoarding Disorder. People with
BDD enjoy a significant drop in symptoms even months after the treatment has ended
(Harrison et al., 2016). Internet-based ERP also shows promising results, potentially making
the treatment far more accessible.
Similarly ERP is commonly used for those with Hoarding Disorder. With the help of
motivational words, exposing clients to anxiety-provoking stimuli such as discarding items
while preventing compulsive rituals such as counting possessions makes it possible to gain
insight about their living conditions. Unfortunately, up to two-thirds continue to exhibit some
symptoms after treatment (Tolin et al., 2015).
Notably, a “third-wave” of CBT is emerging with the addition of mindfulness as a key

feature. As useful traditional CBT is, not everyone positively benefits from it; hence, the
attention to mindfulness-based interventions. It is important to note that this too can be used
in conjunction with traditional CBT and ERP interventions to increase efficacy and prevent
relapse (Fairfax, 2008). There are various approaches to this new wave such as, but not
limited to Mindfulness-Based ERP (MB-ERP), Mindfulness-Based Cognitive Therapy
(MBCT), and Acceptance and Commitment Therapy (ACT). These treatments differ in
approaches but the theory behind this the same. Instead of deliberately trying to change
thoughts, this new wave allows for an acceptance of painful thoughts and feelings for what
they are--just thoughts and feelings. Interestingly, this more compassionate approach to
treatment is also well received by participants with OCD, making drop-outs in treatment less
frequent (Leeuwerik et al., 2020; Key et al., 2017).
Recent studies also support the use of third wave CBT for people with BDD. When
compared with cognitive restructuring and distraction strategy, the new mindfulness-based
intervention was just as effective in reducing thought frequency and even increased positive
affect better than the others (Hartmann, 2015).
PSYC 26 16
On the contrary, there is limited information on the viability of third-wave treatments

for those with hoarding disorders. Alternatives, however, include self-help groups which are
not only more affordable but also less anxiety-provoking than ERP (Muroff , Levis, &
Bratiotis, 2014). It does, however, heavily rely on the client’s desire to be helped.
There are also emerging studies on deep brain stimulation although, at the moment, it
is difficult to recommend, especially for those with comorbidity. On its own, DBS has
underwhelming effects; however, alongside CBT, it has significant results on the reduction of
OCD but not anxiety and depressive symptoms. However, discontinued treatment results in
relapse and even worse symptoms for anxiety and depressive symptoms (Mantione et al.,
2014). Again, using this treatment is not recommended at the moment, however, it can be a
viable option in the future should researchers find an optimal way to utilize this technology.
Trauma-Related Disorders
Evidence-based therapy, such as exposure treatment, is the primary psychological
Association, 2017; Watkins et al., 2018; Kring & Johnson, 2019).
There are several variations of exposure therapy. These include but are not limited to
in vivo exposure, imaginal exposure, virtual reality exposure, and interoceptive exposure. In
vivo exposure involves clients directly facing a feared object, situation, or activity in
real-time. For instance, a person who developed a fear of traveling due to a traffic accident
may be tasked to ride a car—imaginal exposure tasks clients to vividly image the fear object,
situation, or activity. For example, a victim of physical assault may be requested to recall and
describe their traumatic experience to decrease feelings of fear. Another variety of exposure
treatment is virtual reality exposure, which can be an alternative if in vivo exposure is
impractical. For example, a person with a fear of driving might use a virtual simulator, which
mimics the experience of driving a car. Lastly, interoceptive exposure involves intentionally
bringing on physical sensations that are relatively harmless but feared. For example, a person
who experiences panic attacks might be tasked to raise their heartbeat through exercise and
learn that the sensation is not dangerous (American Psychological Association, 2017;Watkins
et al., 2018)
Exposure treatment can help people with PTSD in different ways. Since clients are
repeatedly exposed to trauma-related stimuli over time, they might develop habituation
towards it. In this way, their fear of the particular object, situation, or activity decreases over
time. Similarly, the treatment also helps weaken some learned associations between feared
objects, situations, or activities. People undergoing exposure treatment may also develop
self-efficacy. As they are tasked to face their fears, they learn in the process that they are
capable of confronting their fears and managing their emotions. Lastly, exposure therapy aids
in the process of emotional processing. In relation to discovering that they are capable of
facing their fears, clients can also learn to develop more realistic beliefs about the traumatic
experience and be more comfortable with the experience of fear (American Psychological
Association, 2017; Watkins et al., 2018).
PSYC 26 17
Although evidence-based therapies are considered as a first-line intervention to the

development of PTSD, many psychologists do not provide exposure treatment for their
clients with PTSD because it is time-consuming (Becker, Zayfert, & Anderson, 2004, as cited
in Talkovsky & Lang, 2017). Another study showed that many veterans still had diagnosable
PTSD following even after engaging in evidence-based therapy (Steenkamp, Litz, Hoge, &
Marmar, 2015). Additionally, some even preferred to try other strategies (Markowitz et al.,
2016, as cited in Talkovsky & Lang, 2017). With the lack of dissemination of effective
psychological treatments and preference for different strategies, there is a strong need to
supplement effective treatments and find other inventions and strategies to combat the
symptoms of PTSD. These include but are not limited to meditation-based approaches,
third-wave CBT, and group therapy.
A possible approach to supplement the treatment of PTSD is group therapy or peer

support. Some people with PTSD report experiencing feelings of fear and loneliness. Group
therapy enables people with PTSD to experience validation from fellow survivors who may
have some idea of what they are going through. In a study about former war veterans'
perspectives on peer support for PTSD, results indicated that the most commonly cited
benefit was social support and feeling understood in a way that civilians did not understand
(Hundt et al., 2015). In the same study, they also discovered that group therapy served as an
avenue for other veterans to learn particular coping strategies that might be helpful (Hundt et
al., 2015).
While group therapy may have several benefits, it might not work for everyone.
People with PTSD experience withdrawal and avoidance tendencies. As such, they might not
avail of social support or group therapy even if it is available to them. Despite this, it is
recommended to seek other alternatives that can help prevent or impede the development of
PTSD. Additionally, it is important to note that group therapy and social support are not
primary approaches in treating PTSD and should supplement evidence-based therapies.
Finally, the emerging third-wave CBT also shows promising efficacy in reducing
PTSD symptoms although more rigorous investigations, particularly with controlled studies,
are needed (Benfer et al., 2021). As mentioned earlier in the recommendations for
OCD-Related Disorder Treatment, the goal is not exactly to change the behavior but rather to
allow and accept them without judgment to reduce distress. Since this treatment is less
anxiety provoking than traditional Exposure Treatments, drop-outs are expected to occur less,
consequently reducing relapses of PTSD symptoms due to unfinished programs.
Personal Learnings and Insights
For Winona
When looking for research about prevalence rates for trauma-related disorders, I
discovered that Philippine data on mental health disorders were scarce. There were only a
handful of national studies on OCD-related disorders and trauma-related disorders, most of
which were confined to a particular setting. Unfortunately, there were also no extensive
studies or statistics on the national level for these disorder groups. The lack of pertinent
research and statistics on mental health disorders in the Philippines highlighted the national
government’s need to improve its mental health information systems to make informed and
data-driven decisions for the betterment of mental health care in the Philippines.
PSYC 26 18
For Francine
Mental health is certainly not a foreign concept here in the Philippines, however, it
could be said that it is being treated as one that is “made up.” The stigmatization of mental
health drives people away from taking these disorders seriously; even if people could
possibly be experiencing symptoms that meet the criteria for certain psychiatric disorders,
they are less likely to consult with mental health professionals. The lack of research or
statistics regarding the mental health of Filipinos may be accounted for by the said
stigmatization.
The symptoms that are observed in both obsessive compulsive-related and
trauma-related disorders may be perceived as something an individual can choose to not to
do, the same could be said as well for other psychiatric disorders. As students who currently
major in psychology, there is a call for us to challenge long-standing obstacles in the
acknowledgement and acceptance of the existence of mental health. This may not be an easy
feat, but it could be made possible by communicating the science behind disorders to the
general public in a way that could be easily understood, in a way that humanizes the
individuals who are diagnosed with these disorders.
For Xavi
As someone who has taken mindfulness classes before, the rise of third-wave CBT is
exciting for the future of the mental health industry. I used to only read about advancements
in psychological treatments in textbooks but now, to live through and contribute to relevant
discussions makes learning about Abnormal Psychology so much more meaningful.
Along with this appreciation, however, is the realization that the field still has a long
way to go. Although promising, controlled trials in third-wave CBT are still very limited.
Even more so, studies in the local context are scarce if not non-existent. To push for better
mental health care for everyone, therefore, requires a holistic approach. Research and practice
go hand in hand and important stakeholders such as universities, hospitals/clinics, and even
the government must work together in order to progress the field.
PSYC 26 19
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PSYC 26 29
VII. APPENDICES
Appendix A
Case study: Obsessive-Compulsive Disorder
Personal Data
Karen Rusa is a 30-year-old female raised in New York City by Italian immigrant
parents along with 3 younger siblings. She married Tony shortly after finishing highschool,
her highest educational attainment, and has four children with him.
Social Case History

A. Developmental History
Karen grew up in a strict family setting. At an early age, she was exposed to many
specific rules and guidelines on social behavior from her family, her school, and perhaps most
notably, her church.
Raised as a devout Roman Catholic, the church's rituals for mass, abstinence, and
especially confession greatly concerned her. When she had her First Communion at eight
years old, she suffered from intense guilt about intentionally failing to confess about taking
home a small picture book from school because she was too ashamed to admit it. Her parents’
and teacher’s warnings about eternal punishment in hell haunted her dreams occasionally,
making her even more of a devout believer, paying attention to even the smallest details of
church regulations to “make-up”for her “mortal”sin.
At home, her mother is described as rigid and moralistic who, apart from insisting on
religious practices, was also very strict in maintaining a family schedule for meals and other
routines. This is what Karen best remembers her for, citing that she does not remember her
acts of affection.
Just after graduating high school, Karen married Tony and they would have four
children--two boys, two girls-- by the time she’s twenty-five years old. At thirty, it was clear
that things are not going well as she reports both dissatisfaction with her marriage as well as
problems with raising her children.
Tony, at thirty-two years old, is already on complete physical disability after suffering
from a serious heart condition. Consequently, he left his job as a clerk and would spend most
of his time at home on the couch watching television, convincing Karen that she is
responsible for the chores. Apart from managing her husband, managing children was an
additional burden as they did not respond well with her parental discipline which was not that
consistent either. She would often find her two boys in trouble at school whereas her girls
would often argue, particularly about each other’s weight. These made Karen extremely
frustrated but she was not able to properly air out her concerns. Instead, she would passively
express her frustration in subtle ways, making interactions more tense.
B. Family Data
Karen’s parents were Italian immigrants who moved to New York City, where she was
raised with three younger siblings. There is no mention of socio-economic status nor any
notable psychopathology.
PSYC 26 30
On the other hand, her husband, Tony is on complete physical disability. With him,
she has four children aged 6, 8, 9, and 11. The eldest, Jennifer, is mildly obsese. They live
fairly comfortably in a suburban area.
C. Personality Traits
Karen rates highly in conscientiousness, insisting on faithfully following schedules in

her married home just as her mother did when she was still a child. In addition, she is also
inexpressive when it comes to both pleasant and unpleasant feelings for others, leading to
either a lack of affection or passive-aggressive behaviors.
D. Educational History
The rigid rules and regulations of school are notable influences on her condition.
Exclusively attending parochial schools from grade school to highschool, the teachings of the
church were also very evident in this environment. Her teachers were particularly influential
in her guilt from the aforementioned incident during her First Communion wherein she
believed she was doomed for eternal suffering after failing to confess for all her sins. Despite
this, she was noted as a reasonably good student.
Description of Symptomatology
A. Behavioral Manifestations/ Disturbances
Karen manifests both obsessions and compulsions which she finds most disturbing.
The main focus of her obsession is her children’s safety. In particular, she would think that a
disastrous accident had occurred and she was unable to take it off her mind. At times, she
would even be surprised if proven wrong, even if she receives verbal assurance from her
children’s school.
To manage these, Karen developed a ritualistic behavior of counting. For example,

she believed selecting the first, second, or third item in a grocery store would harm her
children in some way. This is also evident when doing other activities such as smoking or
drinking coffee. She felt the need to reach a certain number of sticks/ cups to prevent a major
accident. Interestingly, whether this number is good or bad is dependent on her children’s age
which was even more distressing for her since she would keep track of their ages. However,
doing so gave her a sense of control over her life even if her preoccupation with them
interfered with her day-to-day activities.
In addition, Karen also
B. Brief History of the Present Disturbances
Given Karen’s environment growing up, her childhood was already characterized by a
general anxiety and concern for order and rituals. As this continued, she started showing
symptoms of obsessions during her teen-age years as intrusive and repetitive ideas began
making her distressed.
PSYC 26 31
Perhaps the most notable incident, however, was that after highschool, during her
pregnancy with her first-born, she witnessed an infant get run over by another child riding a
bicycle. For the rest of the day, she experienced intrusive thoughts of self-harm through
dangerous acts such as jumping off a window or intentionally getting run over by a car. These
were frightening for her as they were unpredictable. Attempts to eradicate these thoughts
through prayer and begging for forgiveness were only temporarily effective.
C. How the Condition Affects Other People
Although her obsessions were indeed disturbing, it was her compulsive rituals that
affected others, particularly her immediate family, the most. Although these were supposedly
her way of protecting her children, it comes off as ambivalent for them as she would often get
angry and even think about physically causing harm.
Her engagement in rituals instead of more appropriate means of interacting with

others affected her social skills. This manifested in her unassertiveness with her spouse, Tony,
when it comes to managing the household and sharing the workload. Instead of calling him
out for his lack of contribution and bossy approach, she would feel frustrated and angry,
looking for subtle ways to get back at him, creating a tense atmosphere. Likewise, she was
unable to express her gratitude to Tony when he would seldomly do something for her.
However unhappy she was, she feared more a change for the worse should she do something
about it.
D. How the Client Perceives and Interprets Their Condition
As with many who are diagnosed with OCD, Karen finds her obsessions disturbing
and anxiety-provoking. She also acknowledges the irrationality of her compulsions but her
anxiety is somewhat relieved when she is faithful to her rituals. Notably, it was from her own
recognition that she has lost control over her compulsive behaviors that she decided to reach
out for professional help.
E. Environmental Triggers
Karen’s triggers to her obsessions and compulsions are items or activities in her
everyday life that can be counted. From the items in the grocery store, cigarette sticks, or
even cups of coffee, she would feel the need to align her choices with numbers associated
with her children’s ages. Not doing so gives her the intrusive idea that she is directly
responsible for harm and accidents that come their way. With that being said, accidents seem
to trigger her guilt about her sins which calls back to major incidents during her childhood
and teenage years.
Similarly, breaks in established rituals, especially those involving the church, also
seem to cause distress. For example, when church masses were no longer required to be
celebrated in Latin, she found it incredibly distressful and refused to participate at all, even if
religion matters much to her.
F. Current Symptoms
Overall, these obsessions and compulsions have led to feelings of depression,

especially in the most recent months. Failure to complete rituals also fueled her anxiety
PSYC 26 32
which manifests in feelings of dread, apprehensions, and even guilt as discussed earlier.
Having these thoughts do not allow her to relax and instead make her feel tense all the time.
G. Summary
Karen’s strict environment growing up had a significant influence in her condition.

Her home, school, and church were not only heavily driven by rituals but also posed negative
consequences for non-adherence. These laid the foundation for her obsessions and
compulsions, manifesting fully during her married life, which was also stressful. Her
husband’s refusal to help out with managing four rowdy children eventually led her to
experience depressive symptoms.
Under Axis I: Clinical Disorders, Karen falls under Obsessive Compulsive Disorder
with both obsessions and compulsions present given the DSM-5 criteria.
Karen reports to often experience intrusive thoughts regarding accidents happening to

her Children (Obsession Criterion A1). Unfortunately, these thoughts were more often than
not confirmed as her children would often find themselves in minor accidents every now and
then. Attempts to suppress these thoughts are present but to no avail as she finds the anxiety
too much to handle (Obsession Criterion B1).
Karen has also developed a compulsive ritual for counting items or activities. These
rituals, although unrelated to accidents, are deemed necessary by Karen to be executed with
precision for fear of causing harm to her children (Compulsion Criterion A1, B1, C1). During
times when she would “fail” to do so, she reported feelings of dread and apprehension
(Compulsion Criterion D1). In the last few months before seeking treatment, she reported
intense feelings of distress from not being able to control these behaviors.
In addition to these, Karen also feels the need to follow home and church rules
faithfully. She even reported feelings of distress when the church decided to change the
language of the mass (Compulsion Criterion B1, D1).
Under Axis II: Developmental Disorders and Personality Disorders, Karen does not
exhibit any symptoms although her social skills are notably underdeveloped.
Under Axis III: General Medical Conditions, Karen does not exhibit any symptoms.
Under Axis IV: Psychosocial and Environmental Problems, Karen’s stressful married
life has the most significant influence on her distress. Her husband does not help out with
chores and her children are difficult to manage. The latter are also frequently involved in
minor accidents, making Karen’s obsession for their safety worse.
In addition, changes in church rituals is an additional source of distress for her.
Under Axis V: Global Assessment of Functioning Scale, Karen gets a score of 62.
Although she is often in distress, she is still able to do most of the family chores and errands
for six people. This, of course, does not mean she manages it well but it is indicative of her
capability to continue with her tasks. Her social functioning, particularly in her family, is
visibly affected but it is largely because the environment makes it difficult for her.
PSYC 26 33
Figure I. Diagnostic Impression Summary: OCD.

Axis I Obsessive Compulsive Disorder
Axis II None
Axis III None
Axis IV Stressful family environment; Changing church rituals
Axis V 62: Moderate symptoms; Moderate difficulty in social

occupational or social functioning
Treatment
As disturbing Karen’s obsessions and compulsions are for her, it is clear that there is
more to address than just that. Her compulsions have led to her having difficulty asserting
herself to her husband as well as managing her children. These have significantly affected her
quality of life. For this reason, her therapist considered ERP as the final treatment strategy
once Karen is able to equip herself with skills that allow her to almost immediately have
genuine control over her family situation.
Their first sessions focused on assertiveness training. Through a daily journal, they
were able to properly assess scenarios herein she was unable to assert herself. She and her
therapist then role-played incidents so that she can get used to more appropriate responses
and confrontations instead relying on passive-aggressive behaviors. In addition, her fears of
being unloved should she use assertive behaviors were also discussed. Once the assertion
training yielded positive results, she and her therapist then discussed effective
child-management skills through operant conditioning. So instead of reinforcing negative
behaviors, she was trained how to properly ignore quarrels and encourage play-time amongst
her children.
Apart from skills-training, Karen and her therapist also addressed her concerns about
religion. However, instead of discussing it between them, she was encouraged to seek priests
who align with her conservative views for an educational discussion on why church rituals,
particularly its delivery in Latin, are changed. Hearing those reasons from them allowed her
to have a renewed interest in church activities with less intrusive anxiety over rituals.
Finally, after being equipped with skills and knowledge that can more immediately
improve her quality of life, Karen underwent Exposure and Response Prevention (ERP). This
treatment was developed to specifically address compulsive rituals through direct or implicit
exposure to stimuli that evoke anxiety. In Karen’s case this manifests in compulsive counting
whenever choosing items or doing certain activities. By gradually exposing her to different
stimuli she is used to (e.g. grocery items, cigarette, coffee cups) while resisting a compulsive
response and seeing out the anxious feelings, the cycle of obsession and compulsion is
gradually broken.
PSYC 26 34
Although ERP is the gold-standard for OCD treatment, it is still possible for Karen to
experience a relapse in her OCD symptoms. Should it happen, it is recommended to undergo
“third-wave” Cognitive-Behavioral Therapy instead of repeating the ERP. Although relatively
new, this new approach to CBT places mindfulness as a core feature of the treatment,
modifying Karen’s relationship with her thoughts and feelings instead of deliberately
changing it (Manjula & Sudhir, 2019). The active acceptance of psychological discomfort
will reduce her distress without necessarily undergoing anxiety-provoking procedures such as
those in ERP.
Still, whether or not Karen would need to undergo another treatment, it is highly
recommended to engage in mindfulness practices that can help her manage negative thoughts
and feelings before they become too much to handle. Breathing exercises, body scans, and
even mindful walking or eating align with the goals of third wave CBT, should treatment be
unnecessary.
PSYC 26 35
Appendix B
Case Study: Post Traumatic Stress Disorder: Rape Trauma
Personal Data
Jocelyn Rowley, a 20-year-old single woman, was a sophomore at a midwestern

university. She grew up in a small midwestern town with her parents and two younger
siblings. Both of her parents were successful in their respective occupations and were active
members of their community. Jocelyn is also the eldest of three children.
Social Case History
A. Developmental History
Jocelyn was 13 years old when she attended summer music camp to play the
trombone. At the time, it was uncommon for a female to play the instrument. As a result, she
would get teased by the boys in her section. One day after rehearsal, some boys from her
section ganged up on her, claiming that girls cannot play the trombone. One of the boys
began wrestling with her and placed his finger inside her shorts into her vagina. She yelled at
him, and he eventually let go and took off with the rest of the boys.
Jocelyn had a boyfriend during her junior and senior years of high school. They were
both 16 years old at the time. A year into their relationship, they became sexually involved
with each other. However, their relationship was put to an end as they both left their
hometown to attend different colleges. Jocelyn shared that there were times wherein her high
school boyfriend pressured her into having sex even when she thought it was too risky or
when she was not interested.
B. Family Data
Jocelyn’s parents were successful in their careers and were involved in both
community and school activities. When she was in high school, Jocelyn’s parents were strict
about dating and curfews. As such, she was not interested in large parties nor drinking.
C. Personality Traits
Jocelyn was described as shy and had difficulties making friends.
D. Educational History
Jocelyn was a straight-A student for most of her time in school. Aside from her
academic feats, she was involved in several extracurricular activities. Although, she had
difficulties making friends, as she was shy and considered nerdy by her peers. When she
entered college, she made a set of new friends while maintaining good grades.
Description of Symptomatology
A. Behavioral Manifestations/Disturbances
PSYC 26 36
Jocelyn sought professional help from her university’s counseling service after
experiencing academic decline and interpersonal problems. Jocelyn displayed attentive
behavior and was often easily startled. If a person were to tap her on the shoulder
unexpectedly, she would overreact, occasionally offending her friends with her response.
When performing daily activities, such as reading, vivid images of men trying to
assault or rob her would surface. Because of this, she had difficulties concentrating as she had
to manage fear from the intrusive thoughts. Almost every night, she would experience
nightmares about men in dark clothing trying to assault her. She stayed up at night to avoid
these dreams, which made her feel irritable and contributed to her problems with
concentration.
Jocelyn also began withdrawing from interpersonal relationships with her friends and
boyfriend and no longer felt interested in them. She was not as emotionally invested in her
relationship with her boyfriend, which sparked arguments and tension between the two.
Additionally, Jocelyn would reject her boyfriend’s physical advances, causing him to distance
himself from her. As for her relationship with her roommates, they complained that she was
overly sensitive and cried at unexpected times.
Jocelyn also felt dissociated from herself. When she passed by a mirror, she was
surprised to see her reflection and could not believe it was her. The rapid onset of the
symptoms made her feel as if she were losing her mind, causing her to seek professional help
from the university’s counseling service.
B. Brief History of the Present Disturbances
Jocelyn’s present disturbances include having intrusive thoughts and memories about
physical brutality and nightmares related to the rape. The nightmares brought upon her
immense fear, causing her to stay up at night. The violent images of physical brutality, mostly
about assault or robbery, would interfere with concentration.
It was also difficult for Jocelyn to trust people, including her friends. At night, she
could not find it in herself to walk alone to the library. She also felt as if there was no one she
could trust to accompany her to the walk. Because she was unable to walk to the library and
study properly, her grades suffered.
When Jocelyn Jocelyn was 13 years old, she attended a summer music camp to play
the trombone. After rehearsal, some boys from her section ganged up on her and teased her
for playing the instrument. One of the boys began wrestling with her and placed his finger
inside her shorts into her vagina. She yelled at him, and he eventually let go and took off with
the rest of the boys. She did not seek psychological help after the assault.
Jocelyn also had a boyfriend during her junior and senior years of high school. They
were both 16 years old at the time. A year into their relationship, they became sexually
involved with each other. After high school, they broke up as they entered different
universities. Jocelyn explained to her therapist that she occasionally felt pressure from her
boyfriend at the time to perform sexual acts, even if she felt as if it were too risky or
uninterested.
PSYC 26 37
C. How the Condition Affects Other People
Jocelyn’s condition severely interfered with her relationship with her boyfriend. She
found herself frequently arguing with her boyfriend. Although, she could not pinpoint the
root of the fights. She also rejected her boyfriend’s physical advances, causing him to
distance himself. These actions propelled her boyfriend to distance himself from her.
Her relationship with her friends and roommates was also affected. Her exaggerated
startle responses offended her friends. On the other hand, her roommates noted her irritable
behavior and complained that she was too sensitive. They also observed she cried at
unexpected times. Jocelyn mentioned that she would not feel safe with anyone to walk her
home at night. This report suggests that Jocelyn also felt that she could not trust the people
closest to her.
D. How the Client Perceives and Interprets Their Condition
Initially, Jocelyn felt as if she were not affected by the incident. She thought that if
she pretended it never happened, she would be okay and live normally. Because of this,
Jocelyn decided not to tell anyone about the incident. Although she started experiencing
difficulties in performing day-to-day activities, she would act as if life were normal. It was
only after two months that she decided to seek psychological aid when she was overwhelmed
with her symptoms, which affected her daily functioning, interpersonal relationships and
academic performance.
When her therapist strongly advised Jocelyn to report the teaching assistant to her
English professor and campus police. However, Jocelyn quickly refused, explaining that
nobody would believe her. Additionally, Jocelyn shared that she did not want to be humiliated
and was afraid of cross-examination.
Sometimes, thoughts about the incident would cross her mind. She would attempt to
put a hold on her intrusive thoughts, but the more she tried not to think about it, the more the
thought occurred. Because of this, she began feeling ashamed for what had happened. She
also tended to blame herself. For example, she pondered whether she wore provocative
clothing or acted in a particular way that seemed sexually inviting.
E. Environmental Triggers
Activities, such as reading, triggered Jocelyn’s intrusive thoughts. She shared that
when she studied, particularly English, she would encounter vivid images of physical
brutality. Similarly, nightmares also evoked immense fear from Jocelyn, as they involved
men assaulting her. Certain actions, such as unexpected shoulder taps, also evoked feelings of
fear and distress. Jocelyn shared that her friends would get insulted by her startled responses.
F. Current Symptoms
Under intrusive symptoms, she mentioned experiencing intrusive thoughts and

memories in the form of nightmares and vivid, violent images. These events made her feel as
if she were reliving the trauma. Under persistent avoidance symptoms, Jocelyn stopped
attending her English course, as it evoked intrusive thoughts. Additionally, she would hide
whenever she crossed paths with the teaching assistant. Under negative alterations in
PSYC 26 38
cognitions and mood, Jocelyn exhibited behaviors that implied that she had a negative
outlook. For instance, she did not want to share that she was raped because she thought it was
humiliating. Jocelyn also felt guilty and tended to blame herself for getting raped. She also
carried a negative outlook towards her friends. She did not trust anyone to walk with her in
the dark and thought that no one would believe her if she opened up about being raped.
Lastly, under alterations in arousal and reactivity, Jocelyn displayed irritable behavior, was
easily startled, and was described as too sensitive.
G. Summary
In her sophomore year of college, Jocelyn Rowley was raped by her English teaching
assistant. Jocelyn believed that she would continue to live a normal life by keeping her
trauma to herself as if nothing had happened. However, over time, she gradually began to
experience several symptoms of PTSD that would interfere with various aspects of her life,
such as her day-to-day activities and her social and social occupational functionings. All
these negative consequences from the trauma have evoked immense fear and caused distress
upon Jocelyn. She felt that she was losing her mind. Given this, after two months since the
incident, she decided to seek psychological aid at her university’s counseling service.
Under Axis I: Clinical Disorders, Jocelyn falls under Posttraumatic Stress Disorder
with several symptoms present given the DSM-5 criteria. Under Criteria A, Jocelyn
experienced rape, which is a form of sexual violence. She reported having recurrent,
involuntary, and intrusive recollections of the incident (Criterion B1). When reading her
English book, Jocelyn would experience intrusive images of her being physically assaulted.
She also experienced nightmares about unfamiliar men in dark clothing attempting to hurt
her, causing her great distress (Criteria B2).
Jocelyn also displayed avoidance symptoms. She made deliberate efforts to stop
intrusive recollections about the incident to the point that it affected her concentration. She
also stayed up at night to prevent nightmares from occurring (Criteria C1). Additionally, she
no longer attended her English course, as the thought of the teaching assistant evoked
feelings of fear (Criteria C2).
She also displayed persistent and exaggerated negative expectations towards the
people around her and herself. In a therapy session, she expressed that she did not feel safe
walking with anyone in the dark. In another session, Jocelyn explained that she did not want
to open about the incident to her friends, campus police, and English professor as she thought
they would not believe her. (Criterion D2). Jocelyn also exhibited erroneous cognitions about
the cause of the rape, thinking that she might have worn a provocative outfit or seemed
sexually inviting (Criteria D3). She often felt guilty and tended to engage in self-blame
(Criterion D4). Given these negative cognitions towards herself and others Criterion D5).
Another symptom she displayed is heightened startle response to unexpected

movements. As mentioned, she was easily startled whenever she was tapped on the shoulder
unexpectedly (Criterion E4). Because of her lack of sleep, coupled with intrusive thoughts
and memories, Jocelyn found it difficult to concentrate on her studies, which affected her
academic performance (Criterion E5). She also experienced nightmares related to the
traumatic incident, which interfered with getting adequate sleep (Criterion E6). She also
PSYC 26 39
reported feeling detached and dissociated from herself.
Under Axis II: Developmental Disorders and Personality Disorders, Jocelyn does not
exhibit personality disorders and mental retardation symptoms.
Under Axis III: General Medical Conditions, Jocelyn does not exhibit any symptoms.
There was no mention of any medical conditions that might have affected the development of
Jocelyn’s PTSD symptoms.
Under Axis IV: Psychosocial and Environmental Problems, Jocelyn experienced some
environmental triggers. Activities that reminded her of the trauma, such as reading, triggered
Jocelyn’s intrusive thoughts and evoked fear and distress. Similarly, nightmares also evoked
immense fear from Jocelyn, making her lack sleep. Unexpected actions, such as shoulder taps
from behind, frighten Jocelyn and cause a reactive response, which has offended some of her
friends.
Jocelyn had problems with her social environment. When she opened about the sexual
assault, her boyfriend and roommates were unsupportive. Her roommates either accused her
of lying about the situation or downplayed the trauma. Her boyfriend’s response was to break
up with her. He was very upset from what he heard and decided to cope with his feelings
about her trauma. Despite Jocelyn’s request not to tell anyone about the incident, her
boyfriend told his friends, sparking gossip in their community. As such, Jocelyn did not
receive adequate support from her loved ones and friends.
Under Axis V: Global Assessment of Functioning Scale, Jocelyn gets a score of 55.
The score falls under the fifth range of 60-51, which states moderate symptoms (e.g.,
intrusive recollections and heightened startle response). Jocelyn also displayed difficulty in
social occupational functioning and social functioning. Because of her symptoms, she had
trouble in school, which made her academic performance decline drastically. In addition, she
was unable to properly manage her relationships with her boyfriend, friends, and roommates.
Figure II. Diagnostic Impression.

Axis I ● Posttraumatic stress disorder
Axis II ● None
Axis III ● None
Axis IV ● Break-up with boyfriend and absence of meaningful

support from her friends
Axis V ● 55: Moderate symptoms or moderate difficulty in

social, occupation, or school functioning
Treatment Recommendations
The treatment for PTSD can either be medical, psychological, or a combination of
PSYC 26 40
both. Medical treatment includes taking antidepressants, such as Selective Serotonin

Reuptake Inhibitors (SSRI) or Serotonin-Norepinephrine Reuptake Inhibitors (SNRI).
Psychological treatments involve exposure treatment, cognitive therapy, and short-term
treatment of ASD.
The first few sessions of therapy were focused on providing Jocelyn a safe space to
express her feelings. When she opened up about getting raped by a teaching assistant to her
boyfriend and roommates, they did not offer any meaningful support. Instead, their
interactions exacerbated her situation and made her feel more alone. Having a safe space to
express her frustrations and anger enables her to emotionally-processes her situation. It can
also aid her in learning how to trust people again.
A. Medication
Exposure to chronic stress and high-intensity traumas can affect several functions of
the brain. These events can have long-lasting effects on the brain and behavior and stimulate
the brain’s fight-or-flight response even in safe environments (Voss & Temple, 2007). As
people with PTSD experience high levels of stress, they may opt to take medications such as
Selective Serotonin Reuptake Inhibitors (SSRI) or Serotonin-Norepinephrine Reuptake
Inhibitors (SNRI) to improve their symptoms. In Jocelyn’s case, she reported experiences of
heightened arousal, avoidance of stimuli related to the trauma, and intrusive recollections of
the trauma. For instance, she would get easily startled by an unexpected tap on the shoulder.
She also reported re-experiencing the trauma whenever she encountered stimuli that
reminded her of the trauma, such as walking in a dark alley or reading her English book. In
conjunction with psychological treatment, taking medication can alleviate her symptoms and
improve her mood, anxiety, and other bodily functions.
However, it is important to note that people respond differently towards medication.

Several side-effects from taking antidepressants include insomnia, diarrhea, and loss of
appetite (Alexander, 2012). As such, medications must be tailored to the person’s needs.
Additionally, a person is expected to relapse if medications are discontinued (Kring &
Johnson, 2019). Should Jocelyn opt for medical treatment, they must monitor her response to
the medication and ensure that she takes them on time.
B. Exposure treatment
Exposure treatment, a cognitive behavioral therapy, is the primary psychological

Association, 2017; Kring & Johnson, 2019).
There are several variations of exposure treatment, such as imaginal exposure, in vivo
exposure, and virtual reality exposure. A strategy that seems fitting for Jocelyn’s case is
imaginal exposure therapy. Should Jocelyn engage in this treatment, she will be asked to face
the fears associated with the rape and recall and describe the traumatic event to reduce her
feelings of fear. She will be working through an exposure hierarchy from less intense fears to
PSYC 26 41
more severe ones. In her case, this might involve walking alone or narrating the traumatic
event to her therapist.
The treatment can address several symptoms in several ways. By re-experiencing the
traumatic event in a safe space, Jocelyn’s fear of actions, people, objects, or situations related
to trauma can decrease over time. Exposure therapy can also help Jocelyn develop
self-efficacy, that she is capable of confronting her fears and managing her emotions.
Additionally, the treatment can also help with emotional processing. For Jocelyn’s case, she
can learn to attach new, more realistic beliefs about her traumatic experience. For example,
she can learn not to blame herself and feel less guilty in the process. Additionally, it might
help her relearn certain behaviors that affect other people, such as her heightened startle
response.
C. Cognitive therapy
Another approach to treating PTSD is Cognitive Therapy, which can supplement

exposure treatment (Kring & Johnson, 2019; Oltmanns et al., 2012). Cognitive therapy aims
to address maladaptive ways of perceiving events in the person's environment and change
overly negative assumptions and beliefs that lead to negative emotions (Ehlers & Clark,
2008; Oltmanns et al., 2012).
Several types of cognitive-behavioral therapy can treat symptoms of PTSD. Cognitive

Processing Therapy (CPT) is a strongly recommended treatment for PTSD as it has been
effective in treating symptoms (American Psychological Association, n.d.). CPT helps clients
modify and unhelpful beliefs related to the trauma, enabling them to create a more healthy
understanding and conceptualization of the traumatic event; This can reduce the clients'
tendencies towards self-blame and guilt (American Psychological Association, 2017; Kring
& Johnson, 2019).
For Jocelyn's case, CPT can help her overcome her guilt and tendency to blame
herself for what happened. In a therapy session, she shared that she felt that she did not fight
her perpetrator hard enough and could have acted provocatively. Engaging in CPT can enable
her to reframe her thoughts about the traumatic rape, reducing the guilt, fear, and negative
thoughts she has towards herself.
PSYC 26 42

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ARP: OCD & Trauma-Related Disorders

Applied Research Project Group 2: Obsessive-Compulsive Related and Trauma-Related

I. Definition of the Disorder

Body Dysmorphic Disorder

According to the classification of hoarding disorder in the DSM-V, an individual

Posttraumatic Stress Disorder

Acute Stress Disorder

II. Statistics or Epidemiology

Obsessive Compulsive Disorder

Interestingly, with the COVID 19 pandemic, prevalence of OCD is at 17.93% just

Body Dysmorphic Disorder

Alcohol dependence; paranoid schizotypal, avoidant and obsessive compulsive

Posttraumatic Stress Disorder

Acute Stress Disorder

III. The Illustrative Case Studies

Genetic Risks of OCD-Related Disorders

Neurological Risks of OCD-Related Disorders

Learning Theories of OCD

Cognitive Model of OCD

Cognitive Etiology of BDD

Cognitive-Behavioral Etiology of Hoarding Disorder

This neurological perspective explains Jocelyn’s symptoms as a result of exaggerated

Pretraumatic environmental factors

Severity and Nature of Trauma

Another contributing factor in the development of PTSD symptoms is the nature of

Learning Theories of PTSD

Operant conditioning can also contribute to the maintenance of avoidance behavior

IV. Diagnostic Impression

Karen reports to often experience intrusive thoughts regarding accidents happening to

In addition, changes in church rituals is an additional source of distress for her.

Figure I. Diagnostic Impression Summary: OCD.

Axis I Obsessive Compulsive Disorder

Axis III None

Axis IV Stressful family environment; Changing church rituals

Axis V 62: Moderate symptoms; Moderate difficulty in social

Posttraumatic Stress Disorder

Another symptom she displayed is heightened startle response to unexpected

Figure II. Diagnostic Impression Summary:PTSD.

Axis I Posttraumatic stress disorder

Axis III None

Axis IV Break-up with boyfriend and absence of meaningful support from

Axis V 55: Moderate symptoms or moderate difficulty in social,

However, it is important to note that people respond differently towards medication.

Several types of cognitive-behavioral therapy can treat symptoms of PTSD. Cognitive

Theoretical recommendations/Practical or Applied recommendations

Notably, a “third-wave” of CBT is emerging with the addition of mindfulness as a key

On the contrary, there is limited information on the viability of third-wave treatments

Although evidence-based therapies are considered as a first-line intervention to the

A possible approach to supplement the treatment of PTSD is group therapy or peer

Personal Learnings and Insights

environment on trauma exposure and posttraumatic stress disorder symptoms: A

review of twin studies. Clinical Psychology Review, 30(1), 101–112.

targeted treatments. Depression and anxiety, 32(8), 550-562.

Alexander W. (2012). Pharmacotherapy for Post-traumatic Stress Disorder In Combat

Veterans: Focus on Antidepressants and Atypical Antipsychotic Agents. P & T : a

peer-reviewed journal for formulary management, 37(1), 32–38.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders:

American Psychiatric Association, 2013.

American Psychological Association. (2017). Cognitive Processing Therapy (CPT).

American Psychological Association.

American Psychological Association. (2017). What Is Exposure Therapy? American

and related disorders. Oxford University Press.

Hongayo, Menelo. (2015). Asian Journal of Multidisciplinary Studies Awareness of