Wk 9: Obsessive-Compulsive and Trauma Related Disorders

• There is a moderate genetic contribution to OCD, hoarding and body dysmorphic symptoms- Heritability is estimated to account for 40 to 50 percent of the variance in whether each of these conditions develops.
• Obsessive-compulsive disorder, body dysmorphic disorder and hoarding disorder share some overlap in aetiology that is particularly apparent for genetic and neurobiological risk factors.
•  For example, people with BDD and hoarding disorder often have a family history of OCD.
• In regard to neurobiological risk, OCD, BDD and hoarding disorder seem to involve some of the same brain regions.
• Brain-imaging studies indicate that three closely related areas of the brain are unusually active in people with OCD.
• 1. orbitofrontal cortex: (an area of the medial prefrontal cortex located just above the eyes)
• 2. caudate nucleus: (part of the basal ganglia)
• 3. the 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.
• A similar pattern emerges when people with BDD view pictures of their own face.
• When people with hoarding disorder are faced with decisions about whether to keep or discard possessions such as old mail, they show hyperactivity in the orbitofrontal cortex and the anterior cingulate compared to a control group.
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• While these genetic and neurobiological risk factors may set the stage for developing one of these ­disorders, why might one person develop OCD and another develop body dysmorphic disorder? ­
• Cognitive–behavioural models focus on factors that might promote one disorder as compared to the other.

• The central goal of cognitive–behavioural theory, then, is to understand why the person with OCD continues to show the behaviours or thoughts used to ward off an initial threat well after that threat is gone.
• The authors argue that for those with OCD, previously functional responses for reducing threat had become habitual and hence difficult to override after the threat was gone.
• (Shock foot pedal experiment)
• 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.

• According to another model, 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 theorised that people with OCD suffer from a biologically based deficit in yedasentience.
• Objectively, 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.

• A different model focuses on 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.
• Trying to suppress a thought may have the paradoxical effect of inducing preoccupation with it

• Cognitive models of BDD focus on what happens when a person with this syndrome looks at his or her body.
• People with BDD can accurately see and process their physical features — the problem does not appear to be one of distortion of the physical features.
• Rather, people with BDD tend to be detail oriented and this influences how they look at facial features.
• Instead of considering the whole, they examine one feature at a time, which makes it more likely that they will become engrossed in considering a small flaw.
• They also consider attractiveness to be vastly more important than do control participants.
• Indeed, many people with BDD seem to believe that their self-worth is exclusively dependent on their appearance.

• In considering hoarding, many take an evolutionary perspective.
• In those situations, it would be adaptive to store any resources you could find. The question, though, is how these basic instincts become so uncontrollable for some people.
• According to this model, hoarding is related to poor organisational abilities, unusual beliefs about possessions and avoidance behaviours.
• Problems with attention interfere with staying focused on the task at hand and even once they do focus on dealing with their possessions, they have difficulty categorising objects and making decisions.
• When asked to sort objects into categories in laboratory studies, people with hoarding disorder tend to be slow, to generate many more categories than others do and to find the process highly anxiety-provoking.

• 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.
• They hold a deep sense of responsibility for taking care of those objects and are likely to resent it if others touch, borrow or remove them.
• Many feel a sense of grief when forced to part with an object.
• These attachments may be even stronger when animals are involved. People who hoard animals often describe their animals as their closest confidants.

• In the face of the anxiety of all these decisions, avoidance is common. Many people with this disorder find organising their clutter so overwhelming that they delay tackling the chaos.
• Avoidance is considered one of the key factors that maintains the clutter.

• Treatments that work for obsessive-compulsive disorder, body dysmorphic disorder and hoarding ­disorder are similar.
• Each of these disorders responds to antidepressant medications.
• As with OCD, many people continue to experience at least mild symptoms of BDD with antidepressant treatment.

• No randomised controlled trials of medications are available for hoarding disorder.
• Much of our knowledge is based on studies of OCD patients who also have hoarding symptoms. Although most studies indicate that hoarding symptoms respond less to medication treatment than do other OCD symptoms.

• The most widely used psychological treatment for the obsessive-compulsive and related disorders is exposure and response prevention (ERP).
• Tailored the exposure treatment to address the compulsive rituals that people with OCD use to ward off threats.
• 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 — for instance, the person touches a dirty dish and then refrains from washing his or her hands.
• 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).
• The exposure component of ERP uses the exposure hierarchy approach.
• Typically, ERP involves refraining from performing rituals during therapy sessions lasting up to 90 minutes as well as during home practice between sessions.
• ERP is highly ­effective in reducing obsessions and compulsions.
• ERP is more effective than clomipramine for the treatment of OCD.

Cognitive approaches to OCD focus on challenging people’s beliefs about what will happen if they do not engage in rituals or challenging their often inflated sense of responsibility.

• The basic principles of ERP are tailored in several ways to address the symptoms of BDD.
• For example, to provide exposure to the most feared activities, 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. 
• These behavioural techniques are supplemented with strategies to address the cognitive features of the disorder, such as the excessively critical evaluations of physical features and the belief that self-worth depends on appearance.

Cognitive approaches to OCD focus on challenging people’s beliefs about what will happen if they do not engage in rituals (Van Oppen et al., 1995) or challenging their often inflated sense of responsibility (Clark, 2006). Eventually, to help test such beliefs, these approaches will use exposure. Several studies suggest that cognitive approaches perform as well as ERP.

• Treatment for hoarding is based on an adaptation of the ERP therapy that is employed with OCD.
• The exposure element of treatment focuses on the most feared situation for people with hoarding disorder — getting rid of their objects.
• Response prevention centres on halting the rituals that they engage in to reduce their anxiety, such as counting or sorting their possessions. 
• As with other exposure treatments, the client and the therapist work through a hierarchy, tackling increasingly difficult challenges as therapy progresses.
• Therapy cannot begin to address the hoarding symptoms until the person develops insight. To facilitate insight, motivational strategies are used to help the person consider reasons to change.
• Once people decide to change, therapists help them make decisions about their objects and can provide tools and strategies to help them organise and remove their clutter. 

Self-help groups, supplemented with structured readings, have been found to be a helpful approach that is less expensive than individual therapy.

 Rather than aiming for a total absence of clutter, family members are urged to identify the aspects of hoarding and clutter that are most dangerous, for example, lack of access to an emergency exit. They can use their concern regarding these issues to begin dialogue and set priorities with the person with hoarding 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.
• In addition to trauma, the diagnosis of PTSD requires that a set of symptoms be present.
• The symptoms of PTSD may develop soon after the trauma but sometimes do not develop for years afterwards.
• Once PTSD develops, symptoms are relatively chronic. 
• Suicidal thoughts are common as are incidents of non-suicidal self-injury.

• In the DSM-5, the symptoms for PTSD are grouped into four major categories.
• 1. Intrusively re-experiencing the traumatic event: recurrent dreams about the trauma. Others are haunted by painful and intrusive memories, often evoked by small sensory cues that can bring on a wave of psychophysiological arousal.
• 2. Avoidance of stimuli associated with the event: Most people with PTSD strive to avoid thinking about the event and some try to avoid all reminders of it. Avoidance usually fails; most people say that they do remember the event all too well and often.
• 3. Other signs of negative mood and thought that developed after the trauma: Many people with PTSD feel detached from friends and activities, and find that nothing in life brings joy. As they wrestle with questions of blame about the event, many will come to believe that they are bad, and others will develop the belief that all people are untrustworthy.
• 4. Symptoms of increased arousal and reactivity: The person with PTSD often feels continuously on guard, monitoring the environment for danger. Laboratory studies have confirmed that people with PTSD demonstrate heightened arousal, as measured by physiological responses to trauma-relevant images.
• This can manifest in tendencies to be jumpy when startled, to have outbursts over small events, and to find it challenging to get to sleep or to sleep through the night.

• Complex PTSD:  prolonged exposure to trauma, such as repeated childhood abuse, might lead to a broader range of symptoms than those covered by the DSM.
• Authors differ in the symptom profiles they link to ­prolonged trauma, but most write about negative emotions, relationship disturbances and negative self-concept.
• Comprehensive review suggests that prolonged trauma may lead to more severe PTSD symptoms but does not seem to result in a distinct subtype with unique symptomatology.
• Given this, the DSM-5 does not include a diagnosis or a specifier for complex PTSD.

• Acute stress disorder (ASD):  Like PTSD, ASD is diagnosed when symptoms occur after a trauma. The symptoms of ASD are fairly similar to those of PTSD, but the duration is shorter; this diagnosis is only applicable when the symptoms last for three days to one month.
• There are two major concerns about the ASD diagnosis.
• 1. the diagnosis could stigmatise short-term reactions to serious traumas, even though these are quite common.
• 2. most people who go on to meet diagnostic criteria for PTSD do not experience DSM-IV-TR diagnoses of ASD in the first month after the trauma 

Nonetheless, those who do experience ASD are at elevated risk of developing PTSD within two years

• PTSD tends to be highly comorbid with other conditions.
•  Among people who had developed PTSD by age 26, almost all (93 percent) had been diagnosed with another psychological disorder before age 21. The most common comorbid disorders are other anxiety disorders, major depression, substance abuse and conduct disorder.
• Among people exposed to a trauma, women are twice as likely to develop PTSD as are men.
• This finding is consistent with the gender ratio observed for most anxiety disorders.
• Women may also face different life circumstances than do men.
•  In studies that control for a history of sexual abuse and assault, men and women have comparable rates of PTSD.
• Culture may shape the risk for PTSD in several ways. Some cultural groups may be exposed to higher rates of trauma and, as a consequence, manifest higher rates of PTSD.
•  Culture 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.

• Many of the risk factors for PTSD overlap with the risk factors for anxiety disorders.
•  For example, PTSD appears to be related to genetic risk for anxiety disorders
• High levels of activity in areas of the fear circuit such as the amygdala 
• Childhood exposure to trauma
• Tendencies to attend selectively to cues of threat
• Also parallel with anxiety disorders, neuroticism and negative affectivity predict the onset of PTSD

• As with anxiety disorders, PTSD has been related to Mowrer’s two-factor model of conditioning.
•  In this model, the initial fear in PTSD is assumed to arise from classical conditioning.
• For example, a man may come to fear walking in the neighbourhood (the conditioned stimulus) where he was assaulted (the unconditioned stimulus). This classically conditioned fear is so intense that the man avoids the neighbourhood as much as possible.
• Operant conditioning contributes to the maintenance of this avoidance behaviour; the avoidance is reinforced by the reduction of fear that comes from not being in the presence of the conditioned stimulus.
• This avoidant behaviour interferes with chances for the fear to extinguish.

• The severity of the trauma influences whether or not a person will develop PTSD.
• In short, among people who have been exposed to traumas, those exposed to the most severe traumas are most likely to develop PTSD.
• Traumas caused by humans are more likely to cause PTSD than are natural disasters.
• For example, rapes, combat experience, abuse and assault are all associated with higher risk than are natural disasters.
• Perhaps these events are seen as more distressing because they challenge ideas about humans as benevolent.

• PTSD appears to be related to dysregulation of the fear circuit, as with anxiety disorders discussed earlier.
• PTSD appears to be uniquely related to the function of the hippocampus.
• Brain-imaging studies show that the volume of the hippocampus is smaller among people with PTSD than among those who do not have the condition.
• That is, smaller hippocampal volume in the non-veteran twins was related to greater likelihood of PTSD in the veteran twins after military service. This suggests that smaller-than-average hippocampal volume probably precedes the onset of disorder.
• The hippocampus plays a central role in our ability to locate autobiographical memories in space, time and context, and in organising our narratives of those memories. Difficulties in organising memories and placing them in context could set the stage for PTSD.
• Brewin (2014) theorises that decreased hippocampal volume could help explain the deficits in verbal memory. 

In sum, hippocampal deficits could contribute to psychological vulnerability to PTSD in two different ways. First, the hippocampal deficits could increase the risk that a person will respond to reminders of the trauma even when they occur in safe contexts. Second, the hippocampal deficits may interfere with organising coherent narratives about the trauma.

• Several types of studies suggest that people who cope with a trauma by trying to avoid thinking about it are more likely than others to develop PTSD.
• Dissociation: feeling removed from one’s body or emotions or being unable to remember the event.
•  Dissociation may keep the person from confronting memories of the trauma. People who have symptoms of dissociation during and immediately after the trauma are more likely to develop PTSD, as are people who try to suppress memories of the trauma.

• Other protective factors may help a person cope with severe traumas more adaptively.
• 1. high intelligence
• 2. strong social support

A surprisingly high proportion of people cope quite well with trauma. For some, trauma awakens an increased appreciation of life, renews a focus on life priorities and provides an opportunity to understand one’s strengths in overcoming adversity.

• Medication for PTSD: One class of antidepressant, the selective serotonin reuptake inhibitors (SSRIs), has received strong support as a treatment. Relapse is common if medications are discontinued.
• Psychological for PTSD:  exposure treatment is the primary psychological approach. 
• Where possible, the person is directly exposed to reminders of the trauma using in vivo exposure — for example, by returning to the scene of the event.
•  In other cases, ­imaginal exposure is used — that is, the person deliberately remembers the event.

• Treatment is likely to be particularly hard and to require more time when the client has experienced recurrent traumas during childhood, as those experiences can interfere with learning to cope with emotions.
• The addition of emotion regulation skills led to several positive gains compared to standard exposure treatment, including diminished PTSD symptoms, improved emotion regulation, enhanced interpersonal functioning and lower rates of post-treatment symptom relapse.

• Several cognitive strategies have been used to supplement exposure treatment for PTSD. Interventions designed to bolster people’s beliefs in their ability to cope with the initial trauma have been shown to fare well in a series of studies.
• Cognitive processing therapy is designed to help victims of rape and childhood sexual abuse dispute tendencies towards self-blame.