Chapter 7 Reading Notes Abnormal PDF

Preview

Summary

ch 7...

Description

Chapter 7 Reading - Obsessive-Compulsive Related and Trauma-Related Disorders ● ●

Obsessive-compulsive - defined by repetitive thoughts and behaviors that are so extreme that they interfere with everyday life Trauma-related disorders - include posttraumatic stress disorder and acute stress disorder, 2 conditions that are triggered by exposure to severely traumatic events

Obsessive-Compulsive and Related Disorders ●

●

● ●

OCD: the prototypical disorder of this cluster, is defined by repetitive thoughts and urges (obsessions), as well as an irresistible need to engage in repetitive behaviors or mental acts (compulsions). Body dysmorphic disorder and hoarding disorder share symptoms of repetitive thoughts and behaviors. ○ People with body dysmorphic disorder spend hours a day thinking about their appearance, and almost all engage in compulsive behaviors designed to address concerns about their appearance. ○ People with hoarding disorder spend a good deal of their time repetitively thinking about their current and potential future possessions. For all three conditions, the repetitive thoughts and behaviors are distressing, feel uncontrollable, and require a considerable amount of time. These syndromes often co-occur. ○ About a third of people with body dysmorphic disorders meet diagnostic criteria for OCD during their lifetime. ○ Up to a quarter of people with hoarding disorder will meet diagnostic criteria for OCD. ○ About one-third of people with OCD experience at least some symptoms of hoarding

Clinical Descriptions of the Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder ●

●

●

●

● ● ● ● ●

The diagnosis of obsessive-compulsive disorder (OCD) is based on the presence of obsessions or compulsions. ○ Most people with OCD experience both obsessions and compulsions. Obsessions are intrusive and recurring thoughts, images, or impulses that are persistent and uncontrollable and that often appear irrational to the person experiencing them. ○ The obsessions of most people with OCD have such force and frequency that they interfere with normal activities. Typically, the person spends hours out of the day immersed in these thoughts, images, or urges. ○ Involve fear of contamination from germs or disease ○ Sexual or aggressive impulses, body problems, religion, and symmetry or order 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. ○ Samuel Johnson suffers from multiple compulsions ○ Many people with OCD feel compelled to repeat a ritual if they did not execute it with precision. Commonly reported compulsions include the following: ○ Pursuing cleanliness and orderliness, sometimes through elaborate rituals, such as showering for hours a day, wiping down all objects as they enter the house, or asking visitors to wash before they enter the house ○ Performing repetitive, magically protective acts, such as counting, touching a body part, solving a math problem, or repeating a word again and again ○ Repetitive checking, such as returning seven or eight times in a row to see that lights, stove burners, or faucets are turned off, windows fastened, and doors locked OCD tends to begin either before age 10 or else in late adolescence/early adulthood Fairly chronic For those diagnosed with OCD, the pattern of symptoms appears to be similar across cultures. In addition to obsessions and compulsions, people with OCD are prone to extreme doubts, procrastination, and indecision. Criteria for OCD: ○ Obsessions and/or compulsions ○ Obsessions are defined by: ■ Recurrent, intrusive, persistent, unwanted thoughts, urges, or images ■ The person tries to ignore, suppress, or neutralize the thoughts, urges, or images ○ Compulsions are defined by: ■ Repetitive behaviors or thoughts that the person feels compelled to perform to prevent distress or a dreaded event ■ The person feels driven to per-form the repetitive behaviors or thoughts in response to obsessions or according to rigid rules ■ The acts are excessive or unlikely to prevent the dreaded situation

○

The obsessions or compulsions are time consuming (e.g., at least 1 hour per day) or cause clinically significant distress or impairment

Body Dysmorphic Disorder ●

●

● ●

● ● ● ● ● ●

●

● ●

People with body dysmorphic disorder (BDD) are preoccupied with one or more imagined or exaggerated defects in their appearance, they perceive themselves as ugly or even “monstrous” in their appearance Women tend to focus on their skin, hair, facial features, hips, breasts, and legs, whereas men are more likely to focus on their height, penis size, or body hair, some suffer from the preoccupation that their body is small or insufficiently muscular People with BDD think about their appearance for 3 to 8 hours per day Also, like people with OCD, people with BDD find themselves compelled to engage in certain behaviors. ○ The most common compulsive behaviors for those with BDD include checking their appearance in the mirror, comparing their appearance to that of other people, asking others for reassurance about their appearance, or using strategies to change their appearance or camouflage disliked body areas (grooming, tanning, exercising, changing clothes, and applying makeup) ○ Some try to avoid being reminded of their perceived flaws by avoiding mirrors, reflective surfaces, or bright lights As many as a fifth of people with BDD endure plastic surgery, and many withstand multiple surgeries. About a third of people with BDD endorse some history of suicidal ideation, and about 20% have attempted suicide To cope with the intense shame they feel about their appearance, people with BDD may avoid contact with others. BDD typically begins in adolescence. About 90 percent of persons diagnosed with the disorder still report symptoms 4 years after diagnosis Many people never receive treatment, in part because mental health professionals often do not ask about these symptoms, and in part because those with the disorder often feel too ashamed to raise their concerns Social and cultural factors surely play a role in how people decide whether they are attractive. ○ Among college students, concerns about body appearance appear to be more common in America than in Europe—as many as 74 percent of American students report at least some concern about their body image, with women being more likely than men to report dissatisfaction Among those who develop BDD, case reports from around the world suggest that the symptoms and outcomes are similar across cultures NOT an eating disorder-- When shape and weight concerns are the only foci, however, clinicians should consider whether the symptoms are better explained by an eating disorder.

●

Criteria for BDD: ○ Preoccupation with one or more perceived defects in appearance ○ Others find the perceived defect(s) slight or unobservable ○ The person has performed repetitive behaviors or mental acts (e.g., mirror checking, seeking reassurance, or excessive grooming) in response to the appearance concerns ○ Preoccupation is not restricted to concerns about weight or body fat

Hoarding Disorder ●

● ●

● ● ● ● ●

●

For people with hoarding disorder, the need to acquire is clearly excessive, and it 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. Many people who hoard are unaware of the severity of their behavior, but to those surrounding them, the consequences of hoarding are clear and sometimes seem quite severe. More than 40 percent had accumulated so many items that they were no longer able to use their refrigerator, kitchen sink, or bathtub, and about 10 percent were unable to use their toilet. ○ The poor hygiene, exposure to dirt, and difficulties with cooking can all contribute to poor physical health, such as respiratory problems. Many family members sever relationships, unable to understand the attachment to the objects. About three-quarters of people with hoarding disorder engage in excessive buying, and many are unable to work, making poverty all too common among people with this condition. About 10 percent of persons with hoarding disorder will be threatened with eviction at some point in their lives. For some, the money spent on acquiring possessions leads to homelessness. About of people with hoarding disorder, much more often women than men, also engage in animal hoarding - doesn’t emerge until middle age or older Hoarding behavior usually begins in childhood or early adolescence. These early symptoms may be kept under control by parents and by limited income, so severe impairment from the hoarding often does not surface until later in life. Criteria for Hoarding: ○ Persistent difficulty discarding or parting with possessions, regardless of their actual value ○ Perceived need to save items ○ Distress associated with discarding ○ The symptoms result in the accumulation of a large number of possessions that clutter active living spaces to the extent that their intended use is compromised unless others intervene.

Prevalence and Comorbidity of the Obsessive-Compulsive and Related Disorders ●

Lifetime prevalence estimates are about 2% for OCD and for BDD, and 1.5% for hoarding disorder. ○ OCD and BDD are both slightly more common among women than men.

●

○ Hoarding is equally common among men and women, but very few men seek treatment. All three of these syndromes tend to co-occur with depression and anxiety disorders. ○ OCD and BDD also tend to co-occur with substance use disorders

Etiology of the Obsessive-Compulsive and Related Disorders ● There is a moderate genetic contribution to OCD, hoarding, and body dysmorphic symp-toms. ○ Heritability is estimated to account for 40 to 50 percent of the variance in whether each ● ●

● ● ●

of these conditions develops. People with BDD and hoarding disorder often have a family history of OCD Brain-imaging studies indicate that three closely related areas of the brain are unusually active in people with OCD: ○ orbitofrontal cortex - an area of the medial prefrontal cortex located just above the eyes ○ caudate nucleus - part of the basal ganglia ○ anterior cingulate When people with OCD are shown objects that tend to provoke symptoms (such as a soiled glove for a person who fears contamination), activity in these three areas increases. BDD appears to be related to hyperactivity of the orbitofrontal cortex and the caudate nucleus. Hoarders show hyperactivity in the orbitofrontal cortex and the anterior cingulate when deciding whether to keep or discard possessions like old mail.

Etiology of OCD ● Cognitive Behavioral Models: ○ The authors argue that for those with OCD, previously functional responses for reducing ○

○ ○

○

the threat become habitual and hence difficult to override after the threat is gone. Other researchers have found that once someone with OCD develops a conditioned response to a stimulus, they are slower to change their response to that stimulus after it is no longer rewarded. OCD is related to a deficit in the intuitive sense of feeling security and closure. Yedasentience is defined as this subjective feeling of knowing that you have thought enough, cleaned enough, or in other ways done what you should to prevent chaos and danger from low-level threats in the environment. ■ It is theorized that people with OCD suffer from a biologically based deficit in yedasentience. Because they fail to gain the intuitive sense of completion and security, they have a hard time stopping their thoughts and behaviors. ■ They know that there is no need to check the stove or wash their hands again, but they suffer from an anxious internal sense that things are not complete. ■ Compulsions are particularly reinforcing because they help relieve this sensation, and they do so even more effectively than self-statements do.

● Thought Suppression: A Cognitive Model of Obsessions ○ This model suggests that people with OCD may try harder to suppress their obsessions than other people and, in doing so, may actually make the situation worse. ■ Several researchers have shown that people with OCD tend to believe that thinking about something can make it more likely to occur. ○ People with OCD are also likely to describe especially deep feelings of responsibility for what occurs. ■ As a consequence of these two factors: ● They are more likely to attempt thought suppression. Consistent with theory, people with OCD report engaging in thought suppression more than others do. ○ Trying to suppress a thought may have the paradoxical effect of inducing preoccupation with it. ■ Suppressing thoughts even briefly led to more intrusions of that thought over the next four days.

Etiology of Body Dysmorphic Disorder ● People with BDD tend to be detail oriented, and this influences how they look at facial features. ○ They look at one detail at a time rather than the whole ○ They become obsessed with one small flaw ● People with BDD seem to believe their self-worth comes exclusively from their appearance

Etiology of Hoarding Disorder ● According to the cognitive behavioral model-- hoarding is related to poor organizational abilities, unusual beliefs about pos-sessions, and avoidance behaviors ● People with hoarding disorder have several different types of problems with cognitive organizational abilities. ○ Problems with attention interfere with staying focused on the task at hand ● These difficulties attending to the task at hand, organizing objects, and making decisions influence almost every aspect of acquiring objects, organizing the home, and removing excessive acquisitions. ● The cognitive model focuses on the unusual beliefs that people with hoarding disorder hold about their possessions. ○ Almost by definition, people with hoarding disorder demonstrate an extreme emotional attachment to their possessions. ○ They report feeling comforted by their objects, being frightened by the idea of losing an object, and seeing the objects as core to their sense of self and identity

Stronger feelings when animals are involved because they described them as their closest confidants. ● Many people with this disorder find organizing their clutter so overwhelming that they delay tackling the chaos. ○

○ Avoidance is considered one of the key factors that maintains the clutter

Treatments of the Disorders Medications ● Antidepressants are the most commonly used medications for obsessive-compulsive and related disorders.

● In the treatment of OCD, clomipramine (Anafranil) is the most commonly used antidepressant. ○ Led to 50% reduction in OCD symptoms, helpful for youth and adults ○ Many people continue to experience mild symptoms while on antidepressant treatment ● Only two randomized controlled trials of medication treatment have been conducted for BDD. ○ Both trials found that antidepressants were more helpful than placebo in reducing symptoms. ○ These trials have provided support for both clomipramine and fluoxetine as treatments of BDD ○ Many people continue to experience mild symptoms while on antidepressant treatment ● Most studies say hoarding symptoms respond less to medication ○ However one study did find success at reducing symptoms with antidepressants

Psychological Treatment ● The most widely used psychological treatment for the obsessive-compulsive and related disorders is exposure and response prevention (ERP). OCD● In the response prevention component of ERP, people expose themselves to situations that elicit the compulsive act and then refrain from performing the compulsive ritual. ● The reasoning behind this approach goes like this: ○ 1. Not performing the ritual exposes the person to the full force of the anxiety provoked by the stimulus. ○ 2. The exposure promotes the extinction of the conditioned response (the anxiety).

● ERP is more effective than clomipramine for the treatment of OCD ○ 25% of clients refuse ERP treatment ○ Highly effective in reducing compulsions and obsessions ● More than three quarters of people who receive this treatment show significant improvement BDD-

● Clients might be asked to interact with people who could be critical of their looks. For response prevention, clients are asked to avoid activities they engage in to reassure themselves about their appearance, such as looking in mirrors. Hoarding-

● The exposure element of treatment focuses on the most feared situation for people with hoarding disorder—getting rid of their objects. ● Motivational strategies are used to help the person consider reasons of change ● Self-help groups, supplemented with structured readings, have been found to be a helpful approach that is less expensive than individual therapy ● Early cognitive behavioral interventions focused on helping clients discard their objects as quickly as possible, hoping to avoid the quagmire of indecision and anxiety that might come from too much focus on evaluating possessions.

Deep Brain Stimulation (for OCD) ●

A treatment that involves implanting electrodes into the brain, for those with chronic OCD that fails to respond even after multiple pharmacological treatments. ● For the treatment of OCD, electrodes are typically implanted into either the nucleus accumbens or a region at the margin of the ventral striatum. ● About half of patients treated with deep brain stimulation attain significant relief with a couple months of treatment

Posttraumatic Stress Disorder and Acute Stress Disorder Clinical Description and Epidemiology ● Posttraumatic stress disorder (PTSD) entails an extreme response to a severe stressor, including recurrent memories of the trauma, avoidance of stimuli associated with the trauma, negative emotions and thoughts, and symptoms of increased arousal. ● The diagnostic criteria define serious trauma as an event that involved actual or threatened death, serious injury, or sexual violation. ● Whereas military trauma is the most common type of trauma preceding PTSD for men, rape is the most common type of trauma preceding PTSD for women ( meeting criteria) ○ 30% of female college students report that they have experienced the use of physical force, threats, or harm after they refused secual contact with a person, with 8.7% reporting that they had experienced physical harm ● The diagnosis of PTSD requires that a set of symptoms be present: ○ Intrusively re experiencing the traumatic event. Like dreams or nightmares about the trauma. Sensory reminders of the event can bring on a wave of psychological arousal.

○ Avoidance of stimuli associated with the event. Avoid thinking about the event and avoid all reminders.

○ Other signs of negative mood and thought that developed after the trauma. Feel detached from friends and activities and find that nothing in life brings them joy. Develop the belief that all people are untrustworthy. ○ Symptoms of increased arousal and reactivity. Feels continuously on guard, monitoring the environment for danger. ● Once PTSD develops, symptoms are relatively chronic. ● Suicidal thoughts are common among people with PTSD ● It has been argued that prolonged exposure to trauma, such as repeated childhood abuse, might lead to a broader range of symptoms than those covered by the DSM criteria for PTSD.

● ● PTSD tends to be highly comorbid with other conditions. ○ Most common is anxiety disorders, major depression, substance abuse, and conduct disorder. ● Two-thirds of those with PTSD at age 26 had experienced another anxiety disorder by age 21. ● Among people exposed to a trauma, women are twice as likely to develop PTSD as are men ● Culture may shape the risk for PTSD in several way...