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OBSESSIVE-COMPULSIVE

-
RELATED AND TRAUMA-
RELATED DISORDERS
OBSESSIVE-COMPULSIVE- RELATED AND
TRAUMA- RELATED DISORDERS
 Obsessive-compulsive disorder and the trauma-related
disorders are listed in the anxiety disorders chapter in
the DSM-IV-TR.

OBSESSIVE-COMPULSIVE AND RELATED
DISORDERS
We will focus on three disorders in this section:
 obsessive-compulsive disorder (OCD)
 body dysmorphic disorder
 hoarding disorder
1. OBSESSIVE-COMPULSIVE DISORDER

 Obsessions are intrusive and recurring thoughts, images, or
impulses that are persistent and uncontrollable (i.e., the
person cannot stop the thoughts) and that usually appear
irrational to the person experiencing them
 Compulsions are repetitive, clearly excessive behaviors or
mental acts that the person feels driven to perform to reduce
the anxiety caused by obsessive thoughts or to prevent some
calamity from occurring
 Pursuing cleanliness and orderliness, sometimes through
elaborate rituals
 Repetitive checking to ensure that certain acts are carried out
1. OBSESSIVE-COMPULSIVE DISORDER
 OCD tends to begin either before age 10 or else in late
adolescence/early adulthood
 Common among women
 Two-thirds meet criteria for major depression during
their lifetime.
 Substance use is also common
 About one-third of people with OCD experience at least
some symptoms of hoarding
Proposed DSM-5 Criteria for
OBSESSIVE-COMPULSIVE DISORDER
1. Obsessions (recurrent, intrusive, persistent, unwanted
thoughts, urges, or images that the person tries to ignore,
suppress, or neutralize) or

2. Compulsions (repetitive behaviors or thoughts that a
person feels compelled to perform to prevent distress
or a dreaded event or in response to an obsession)

3. The obsessions or compulsions are time consuming (e.g.,
require at least 1 hour per day) or cause clinically
significant distress or impairment
Etiology of OCD
 There is no absolute signal from the environment.
 Rather, most of us stop when we have the sense of “that
is enough.” Yedasentience is defined as this subjective
feeling of knowing
 Behavioral models emphasize operant conditioning of
compulsions. That is, compulsions are reinforced because
they reduce anxiety
 Thought suppression
2. BODY DYSMORPHIC DISORDER
 preoccupied with an imagined or exaggerated defect in
their appearance
 On average, people with BDD think about their
appearance for 3 to 8 hours per day
 BDD occurs slightly more often in women
 The most common comorbid disorders include major
depressive disorder, social anxiety disorder, obsessive-
compulsive disorder, substance use disorders, and
personality disorders
Proposed DSM-5 Criteria for
BODY DYSMORPHIC DISORDER

1. Preoccupation with a perceived defect or in appearance

2. The person has performed repetitive behaviors or mental
acts (e.g., mirror checking, seeking reassurance, or excessive
grooming) in response to the appearance concerns

3. Preoccupation is not restricted to concerns about
weight or body fat
ETIOLOGY OF BDD

 When looking at visual stimuli, people with BDD appear
to focus on details more than on the whole

 Indeed, many people with BDD seem to believe that their
self-worth is exclusively dependent on their appearance
3. HOARDING DISORDER
 Hoarding disorder, the need to acquire is only part of the
problem.
 The bigger problem is that they abhor parting with their objects,
even when others cannot see any potential value in them
 Although hoarding is more common among men than among
women
 The accrual of objects often overwhelms the person’s home.
 Hoarding was not recognized as a diagnosis until the DSM-5.
 Although hoarding is often comorbid with OCD, it can also occur
among those who do not have OCD symptoms. Depression,
generalized anxiety disorder, and social phobia are common
among people diagnosed with hoarding
 Hoarding develops among people with schizophrenia or dementia
Proposed DSM-5 Criteria for
HOARDING DISORDER
1. Persistent difficulty discarding or parting with
possessions, regardless of the value others may
attribute to these possessions

2. Strong urges to save items and/or distress associated
with discarding

3. The symptoms result in the accumulation of a large
number of possessions that clutter key areas the home
or workplace to the extent that their intended use is
no longer possible unless others intervene.
ETIOLOGY OF THE OBSESSIVE
COMPULSIVE AND RELATED DISORDERS
 Brain-imaging studies indicate that three closely related
areas of the brain are unusually active in people with
OCD the orbitofrontal cortex (an area of the medial
prefrontal cortex located just above the eyes), the
caudate nucleus (part of the basal ganglia), and the
anterior cingulate
ETIOLOGY OF HOARDING DISORDER
 In considering hoarding, many take an evolutionary
perspective (Zohar & Felz, 2001).

 According to the cognitive behavioral model, hoarding is
related to poor organizational abilities, unusual beliefs
about possessions, and avoidance behaviors (Steketee &
Frost, 2003)
TREATMENT OF THE
OC AND RELATED DISORDERS
 Each of these disorders responds to serotonin reuptake
inhibitors.
 The major psychological approach is exposure and
response prevention, although this treatment is tailored
for the specific conditions.
 The most commonly prescribed SRI for OCD is
clomipramine (Anafranil; McDonough & Kennedy, 2002)
 “Selective” serotonin reuptake inhibitors (SSRIs) are a
newer class of SRIs that have fewer side effects.
 Patients with hoarding disorder demonstrated as much of
a response to the SSRI paroxetine (Paxil) as did those
with OCD (Saxena, Brody, Maidment, et al., 2007).
PSYCHOLOGICAL TREATMENT
 The most widely used psychological treatment for the
obsessive- compulsive and related disorders is exposure
and response prevention (ERP).
 This cognitive behavioral treatment was pioneered in
England by Victor Meyer (1966) as an approach for OCD.
 Several trials have shown that cognitive behavioral
treatment (CBT) produces a major decrease in body
dysmorphic symptoms compared to control conditions
(Looper, 2002)
 Hoarding Disorder Treatment for hoarding is based on
the ERP therapy that is employed with OCD
POSTTRAUMATIC STRESS
DISORDER AND ACUTE STRESS
DISORDER
PTSD
 Posttraumatic stress disorder (PTSD) entails an
extreme response to a severe stressor, including increased
anxiety, avoidance of stimuli associated with the trauma,
and symptoms of increased arousal
 In addition to PTSD, the DSM includes a diagnosis for
acute stress disorder (ASD). ASD is diagnosed when
symptoms occur between 3 days and 1 month after a
trauma. The symptoms of ASD are fairly similar to those of
PTSD, but the duration is shorter.
 Culture also may shape the types of symptoms observed
in PTSD. Ataque de nervios, originally identified in Puerto
Rico, involves physical symptoms and fears of going crazy
in the aftermath of severe stress and thus is similar to
PTSD
Proposed DSM-5 Criteria for
POSTTRAUMATIC STRESS DISORDER
 A. The person was exposed to death or threatened death, actual
or threatened serious injury, or actual or threatened sexual
violation, in one or more of the following ways: experiencing the event
personally, witnessing the event, learning that a violent or accidental
death or threat of death occurred to a close other, or experiencing
repeated or extreme exposure to aversive details of the event(s)
 B. At least 1 of the following intrusion symptoms:
1. Recurrent, involuntary, and intrusive distressing memories of
the trauma, or in children, repetitive play regarding the trauma
themes
2. Recurrent distressing dreams related to the event(s)
3. Dissociative reactions (e.g., flashbacks) in which the individual
feels or acts as if the trauma(s) were recurring
4. Intense or prolonged distress or physiological reactivity in
response to reminders of the trauma(s)
Proposed DSM-5 Criteria for
POSTTRAUMATIC STRESS DISORDER
 C. At least 1 of the following avoidance symptoms:
1. Avoids internal reminders of the trauma(s)
2. Avoids external reminders of the trauma(s)
 D. At least 3 (or 2 in children) negative alterations in cognitions
and mood that began or worsened after the trauma(s):
1. Inability to remember an important aspect of the trauma(s)
2. Persistent and exaggerated negative expectations about one’s self,
others, or the world
3. Persistently excessive blame of self or others about the trauma(s)
4. Pervasive negative emotional state
5. Markedly diminished interest or participation in significant
activities
6. Feeling of detachment or estrangement from others
7. Persistent inability to experience positive emotions
Proposed DSM-5 Criteria for
POSTTRAUMATIC STRESS DISORDER
 E. At least 3 (or 2 in children) of the following
alterations in arousal and reactivity that began or
worsened after the trauma(s):
1. Irritable or aggressive behavior
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance
 F. The symptoms began or worsened after the trauma(s) and
continued for at least one month
DSM-IV-TR Criteria for
ACUTE STRESS DISORDER

1. Exposure to a traumatic event causing extreme fear,
helplessness, or horror
2. During or after the event, the person experiences
dissociative symptoms
3. The event is reexperienced intrusively in dreams,
thoughts, or intense reactivity to reminders
4. The person feels numb, detached, or unable to
remember the event
5. Increased arousal or anxiety
6. Symptoms occur within the first month after the
trauma
DSM 5-TR Criteria for
ACUTE STRESS DISORDER
 A. The person was exposed to death or threatened death,
actual or threatened serious injury, or actual or threatened
sexual violation, in one or more of the following ways:
experiencing the event personally, witnessing the event,
learning that a violent or accidental death or threat of death
occurred to a close other, or experiencing repeated or
extreme exposure to aversive details of the event(s)
 B. At least 8 of the following symptoms began or worsened
since the trauma and lasted 3 to 31 days:
1. Recurrent, involuntary, and intrusive distressing memories of
the traumatic event
2. Recurrent distressing dreams related to the traumatic event
DSM 5-TR Criteria for
ACUTE STRESS DISORDER
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or
acts as if the traumatic event were recurring
4. Intense or prolonged psychological distress or physiological reactivity at
exposure to reminders of the traumatic event
5. Subjective sense of numbing, detachment from others, or reduced
responsiveness to events
6. Altered sense of the reality of one’s surroundings or oneself (e.g., seeing
oneself from another’s perspective, being in a daze)
7. Inability to remember at least one important aspect of the traumatic
event
8. Avoids internal reminders of the trauma(s)
9. Avoids external reminders of the trauma(s)
10. Sleep disturbance
11. Hypervigilance
12. Irritable or aggressive behavior
13. Exaggerated startle response
14. Agitation or restlesssness
ETIOLOGY OF PTSD
 two-thirds of people who develop PTSD have a history of
another anxiety disorder.
 high levels of activity in areas of the fear circuit such as
the amygdala (Rauch, 2000),
 childhood exposure to trauma (Breslau, 1995), and
tendencies to attend selectively to cues of threat
 PTSD has been related to the two-factor model of
conditioning.
 PTSD appears uniquely related to the function of the
hippocampus. (SMALLER)
 The hippocampus is known for its role in memory,
particularly for memories related to emotions
TREATMENT OF PTSD AND ASD

 One class of antidepressant, the selective serotonergic
reuptake inhibitors (SSRIs), has received strong support as
a treatment for PTSD.

 Relapse is common if medications are discontinued.
PSYCHOLOGICAL TREATMENT OF PTSD
 In PTSD, the focus of exposure treatment is on memories and
reminders of the original trauma, with the person being
encouraged to confront the trauma to gain mastery and
extinguish the anxiety. Where possible, the person is directly
exposed to reminders of the trauma in vivo—for example, by
returning to the scene of the event.

 In other cases, imaginal exposure is used—the person
deliberately remembers the event

 Therapists have also used virtual reality (VR) technology to treat
PTSD, because this technology can provide more vivid exposure
than some clients may be able to generate in their imaginations.
PSYCHOLOGICAL TREATMENT OF ASD
 Short-term (five or six session) cognitive behavioral
approaches that include exposure appear to do so.

 The positive effects of these early interventions appear to
last for years

 Exposure treatment appears to be more effective than
cognitive restructuring in preventing the development of
PTSD