COP Ch03-2024 default.txt PDF

Hello again. The purpose of this recording is to cover Chapter 3, the obsessive-compulsive disorders, although technically what we'll be covering are the obsessive-compulsive and related disorders, which I'll explain at some point. So, I'll start off by reminding you of this slide that I believe I showed you before, and this is about how the DSM changed from the DSM, basically, 4 to the 5, where they used to have a larger group of anxiety disorders, larger in the sense that there were more disorders included. And with the change, they still had a group of disorders called anxiety disorders, which is what we talked about in Chapter 2. But then they created two new categories or chapters in the DSM, one called the obsessive-compulsive and related disorders, which is what I meant previously when I said that's what we'll be talking about, even though your book chapter, I think, is just called obsessive-compulsive disorders. It's obsessive-compulsive related disorders because there are obviously things in there that are different than obsessive-compulsive disorders. So, they moved that one in there, plus some others that I'll get to shortly. The other new category is the trauma and stress-related disorders, where they moved post-traumatic stress disorder and acute stress disorder into that, plus a few other ones also. And so, what we're doing today is talking about obsessive-compulsive and related disorders. The next week, we'll get to the trauma and stress-related disorders. Just one point to make is just because they have put these in different categories doesn't mean that they're not still highly related. This anxiety is still a major component of all of these. And as you'll see, many of the ideological models that we'll discuss will be similar to the ones that we talked about associated with chapter two, and also some of the treatments, particularly exposure-based treatments, both for OCD-related disorders and for trauma and stress-related disorders, are going to be similar to treatments we talked about associated with anxiety disorders and that you'll talk about in your tutorial this week. So, what are these obsessive-compulsive related disorders? As I've noted, in the DSM, they removed OCD from where it was and put it in with a group of other disorders. And these include body dysmorphic disorder, sometimes referred to as BDD, hoarding disorder, one that's harder to say, trichotillomania, also known as hair-pulling disorder, and excoriation, also known as skin-picking disorder. And so, we will go back and we will talk about all of these in varying degrees. We will spend most of the time today talking about obsessive-compulsive disorder, and then we'll spend more time on BDD than these other three, primarily because we know more about BDD. And I know more about it. I've done research on it, published in the area. But the others are quite interesting. And why are they in here in the same category with OCD? Well, at least as noted there, one of the reasons is the fact that all the disorders in this group involve repetitive thoughts or behaviors. And when we go through them, you'll see that, yes, that's true. However, there are also differences. And many researchers and or clinicians have argued against the validity of the category, that they basically put things in it that probably didn't go together as well as we'd hoped. And the validity of the category is poor. These researchers, in particular, argued that there might be three groups of disorders that are put into this one. Those groups being the compulsive disorders, which would be like OCD and BDD, versus the impulsive disorders, which would be trichotillomania and skin-picking disorder. And so, compulsive and impulsive are not the same thing. Compulsive refers to being driven to do something, even despite negative consequences of something, whereas impulsive refers to acting on something without really thinking, acting quickly without thinking about it. And so, again, they're arguing that those groups of disorders are sort of driven by different processes. And then there's one that's in there that we haven't mentioned yet, right? That's hoarding, which is basically, at least according to these researchers, largely unique. So, back to chapter three with that bit of background, just keeping in mind that the chapter is called obsessive-compulsive disorders, whereas in the DSM, it's obsessive-compulsive and related disorders. Remember, each chapter has learning objectives, and these are the ones actually written by the author of the chapter. So, you'll notice that each week they might be worded slightly differently. That's because you've got different authors writing different chapters. And what I try to cover should at least cover these, but I may sometimes cover additional material. And you'll notice these learning objectives, the first three are pretty much specific to OCD. So, I go into a fair amount of detail about nature of diagnostic criteria of OCD, then epidemiology, etiology, and treatment, again, of OCD. And then the fourth one is just giving more of an overview of the remaining disorders, as I said I would do. And we will spend a little bit more time on BDD, body dysmorphic disorder, than we will on the other three. And as I've done with other disorders, and I'll sort of try to do during the rest of this course is I'll spend time talking on these four general areas. Description, what does it sort of look like? What are the diagnostic criteria? Epidemiology, how common is it? Etiology, what are the causes and treatment? Now, I will do that for OCD, and that's where we are right now. I won't do all that for the other three just because we don't know enough about some of them. And it's sort of beyond the scope of the chapter to try to go into that much detail for the other three. So, regarding the diagnosis of OCD, this is a sort of summary slide of the key features. As the name implies, and as most people probably think they understand, there's two real primary components to obsessive-compulsive disorder. That's obsessions and compulsions. So, obsession, here's a sort of quick definition, intrusive impulses or images of a distressing nature. Again, the distressing part is important because it's not just an image that might be a pleasant sort of thing. It's something that the person doesn't want to have there. And there's a whole long list of types of obsessions, but some common ones are listed there. Most people think of contamination when they think of OCD, but there's many other kinds too. And then the other broad aspect of the disorder is the compulsion. So, repetitive behaviors that the person feels compelled to perform. And there's some examples there. Again, most people think of the first one, cleaning. So, they think of contamination fears and cleaning. And yes, people with OCD do sometimes do that, but they have many other ones too. And not just things that you do, not just sort of motoric sort of things. So, not things just revolving your hands where you watch things or check things. It can also be things in your mind. So, checking things, saying things in your mind, repeating things in your mind, those can all be examples of compulsions. So, again, this is sort of a summary slide. Let's look more closely at the DSM criteria. Oh, by the way, the other important thing I forgot to say is just that it does cause marked interference with a person's life. So, many people may say that they are OCD or they do OCD kind of things. And they may be, but they also may mean that they have a tendency to obsess and have some compulsions. But it really may not be to the level of interfering with someone's functioning. If someone really has OCD, it has to affect their functioning quite significantly. And this disorder used to be viewed as something in the realm of like schizophrenia in terms of just how bad it was. I mean, you could see somebody that just really looked like they could hardly function. Now, we know that there's a lot that can be done to help people with this disorder. But again, we're talking about a fairly severe disorder in terms of interference with people's functioning. So, now to where I thought it was a second ago to the DSM definition of these things. And the first thing to focus on here is the part at the very beginning there, the presence of obsessions, compulsions, or both. And this is one of those times when one little word is very important, and the word that's very important there is or. So, what that means is that to meet the diagnostic criteria for OCD, someone actually does not have to have both obsessions and compulsions. Because it says or, it means you could have obsessions and just obsessions, or you could have just compulsions, or you could have both. Now, the prototypical case and probably statistically the most common cases do have both. But you do sometimes find instances where someone has obsessions but not compulsions or vice versa. And technically, as long as they meet the other criteria, they would meet the criteria for OCD. Now, to the longer definition now of both obsessions and compulsions. So, on this page, we have the longer definition for obsessions, and they have two characteristics also. So, you've got the persistent recurrent thoughts, urges, or images that are experienced as intrusive or unwanted. So, we sort of talked about this already, and they cause marked anxiety or distress. So, it's something in your mind that you don't want to be there. But the second part is important too, that the person attempts either to ignore or suppress them. So, they try to do something about it. And often, that's what the compulsions are. But you can, again, have obsessions without compulsions if they basically try to ignore them or suppress them. So, that's the longer definition of obsessions. Now, the longer definition of compulsions, repetitive behaviors, which include, I mean, DSM words it as repetitive behaviors or mental acts. But you should think of it, I view it as they're both behaviors, but they're either sort of motoric external behaviors or internal behaviors. So, it could be stuff like hand-washing, ordering, checking, things that you think of when you think of OCD. But it could also be mental acts. So, things like, yes, praying, counting, repeating words. The person feels sort of driven to do this. It's typically in response to an obsession. But again, you could have compulsions without obsessions. And in that case, it would be the latter thing. They're according to certain rules that must be applied. Like someone has the compulsion to say something in their mind seven times and always has to be that way. And they may not necessarily have this obsession that triggers it. So, that's why they could have compulsions and not obsessions. But the majority of time though, they do have the obsession and the compulsion is what follows it. So, the second part there of the definition of compulsion, the behaviors are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation. So, in other words, they feel really bad about something. And what they're doing is trying to prevent that and to reduce the anxiety about whatever it is. However, as noted there, they're either not connected in a realistic way or they're with what they're designed to neutralize or it's excessive. So, I mean, by excessive, we mean, if someone feels the urge to wash their hands one time or maybe two times, that's not excessive. And that is connected with something probably at least, certainly in this day and age it is. But if someone felt the need to do it 20 times, 30 times, 40 times, that would be excessive. If someone leaves the house and they think, did I turn the lights off? Did I leave the stove running? And then they go back to check. If they do that one time, that's not excessive. So, that's not really meeting this definition. But if they go back 20 times, 30 times, it is. So, that's what we're getting at there, that it's excessive or again, not connected. So, sometimes people with the compulsions that say they don't have an obsession might say, they're driving down the road and they see something and they have to say some word in their mind seven times. That's not necessarily connected in any kind of realistic way with preventing some kind of dreaded event, but yet they still feel driven to do it. So, that's sort of an explanation of of those rules one and two for what, those definitions one and two for compulsions. So, the next criterion is that B criterion there. It has to do with just a way of figuring out how severe this is. The obsession and compulsions are time consuming. So, I sort of gave you examples in the previous slide. Like if somebody was checking the stove or whatever and they checked it one time, it would delay them two minutes or whatever. And that again would not meet the criteria for being excessive or time consuming in this B criteria. But if they did it over and over and over again, and it took them hours, then that's what we're talking about here. And I mean, the one hour, it's an example there, example more than an hour. If it's more than that, obviously it would be time consuming. I mean, you shouldn't interpret this extremely literally, like if it was 59 minutes, then you'd say they don't meet the criteria for OCD necessarily. They're giving you an example and it involves some degree of clinical judgment. It also has to create a clinically significant distress. So, the people have to say, I really don't want to be this way. This is causing me problems. Often it's very clear that it is causing problems in social life, in their work, other areas of functioning. If it's not, then it may be sort of traits that are related to OCD, but not a full diagnosis of OCD. The last two criteria there, most disorders you'll see have something like this. We would have talked about this last week, that you have to rule out that it's not due to something else. And typically what you're ruling out is that it's not some sort of physiological effect, like of a medication or something, and then rule out that it's not a different mental disorder. So, the C criterion there, the obsessive-compulsive symptoms are not attributable to the physiological effects of a substance. Exactly what that would be, there's probably not a whole lot of drugs that create this, but if someone's coming off of certain medications or taking certain medications or abusing certain medications, they could certainly have some symptoms that might resemble this. Notice there it says, or another medical condition, and you might be asking yourself, what do they mean another medical condition? What's the first medical condition? Well, this is the DSM world where they think of everything psychiatric or mental as being a medical condition. So, the other medical condition is, in their mind, OCD. So, that's a change, by the way, in the DSM-5 that didn't used to be there. It used to say a general medical condition, but now they use the term other just to imply that all disorders in the DSM are medical conditions, which is not something that everyone believes, but that's, again, the way the DSM is sort of conceptualized. Now, the last criterion there, I haven't put the whole thing because it's sort of a long list, but it's not better explained by another mental disorder. So, it's not really just a phobia or it's not really post-traumatic stress disorder or it's not really schizophrenia, and each of those disorders has a sort of way that you need to go through figuring out which one it really is. We'll see, again, that OCD and PTSD are very similar in some ways, and the full similarity might not become clear until we've talked about PTSD next week. But you did talk about phobias last week, and so you could think about how something with OCD might be confused with a phobia. There was even a question on the quiz about the guy that avoided airplanes, and it would sort of depend on why he avoided airplanes. Is he afraid of contamination, germs from people, or is he afraid of crashing, or is he afraid of not being able to escape? In that case that I gave you last week, it was afraid of not being able to escape, which made it really more consistent with agoraphobia. But if I had said he was worried about contamination and he had obsessive thoughts while he was there and compulsions to clean and it was hard to do it on the airplane, then it might be OCD. So, a lot of these things, they take quite a bit of information, but the point of that last criterion is we want to be clear that this is not a different disorder. Now, another interesting thing about OCD, which has changed with the DSM-5, is that you can specify the level of insight. Sometimes people completely understand that what they're doing is irrational. They may say, you know, I know this doesn't make sense, but I still feel like I have to just do it again. You know, I check the stove and I leave the house and I know it's turned off and I just have to go back again. I know it's crazy, but I just have to do it. Something along those lines. At the other end of the sort of spectrum, you can have people that seem to have very little insight and seem to somewhat delusional about it. In earlier editions of the DSM, that would not have been diagnosed as OCD. It had to be diagnosed as something like a psychotic disorder. They had to have some degree of awareness. That's no longer the case. The vast majority of people with these disorders do have some degree of awareness. So, they would either have good, fair, or perhaps poor insight. But there's a small subset where they seem to have absent insight and you could specify that. This, by the way, as noted there, applies to the other obsessive compulsive related disorders too. So, when we start talking about body dysmorphic disorder, for example, you can see cases where they may have delusional beliefs that their face looks different, for example. And it would still be considered body dysmorphic disorder, whereas in the past it would not. So, just a little bit more about obsessions and compulsions. I said that there's sort of a long list of types of obsessive thoughts. So, here is a list. There's probably much more. There are probably much more than this. But these are some of the common ones. And I've talked about some of these already. So, doubting is a very common one. Did I do that? Did I take the medication I was supposed to take? Did I turn the appliance off? Did I check this? Did I check that? Then there's the contamination type, which most people think of when they think of OCD. But again, it's not the only kind. There are many other kinds too. And interestingly, this one can go different ways. So, the contamination can be a concern about yourself, like I'm going to catch something. But it could also be the other way around. I actually had worked with a guy years ago where he was very concerned about giving illnesses to other people, which at the time seemed quite unusual. And he was sort of the only case like that that I remember working with. Now, of course, with various things going around and we're told to be careful both ways, it's probably not so uncommon. But not everybody has obsessions about it. So, we're talking here about not just concerns about, but actual obsessions about it. Then there's other ones though that people may not realize, like nonsensical, where they just have this fear, like this image of themselves shouting out of control, taking their clothes off, or doing things that might hurt people. So, the aggressive one there, where they might have this impulse to stab somebody. I mean, you could sometimes be working with an OCD client and they'd say, well, right now I'm having this impulse of stabbing you, the therapist. And if you know the person has OCD, it's actually not anything to be concerned about. If the person is more like a psychopath, then maybe you should be getting out of the room quickly. But if it's OCD, it doesn't mean they're going to do these things. It means this is the frightening thought that they're having. And there's other ones there too. Sometimes the sexual obsessions or religious obsessions, the blasphemous. A guy I used to know, he had this concern that he was going to curse God in his mind. And it was a horrible fear of him. He was raised very religious and he didn't outwardly do it, but it was this concern that he was going to do it. Then you could have things like accidental harm to others. Did I run over somebody in the car? Did I step on someone? Did I injure someone somehow? Horrific images. These are really unusual ones. And there's an example there. And sometimes this is where you start asking yourself, is this an obsession or is this something that really happened? Is it PTSD where someone's telling you about some sort of trauma that they've experienced? Just based on that, it's sometimes hard to tell. And then the last category, the nonsensical thoughts where they might just have numbers, letters, songs, things they get in their head and they can't get rid of them. Again, keep in mind that it has to be unwanted thoughts. So the idea of songs, I mean, sometimes people that are musicians, you get a song in your head and it's just sort of there all day long and that's not a bad thing. But if it's in the context of unwanted thoughts, it potentially could be. So that's a list of various types of obsessions. Here are some various types of compulsions. You can have counting where you see things and you have to count them. And things like you're sitting in class and you have to count the number of tiles on the ceiling or on the floor, or you're driving down the road and you feel like you have to count the number of windows on a building, which of course could be quite dangerous if you're driving. Checking, I've given you some examples of that already. Did I check the stove? Did I check the doors? Did I check the locks? Washing, that's the one that people think of the most associated with contamination kind of fears. But again, it's only one of many. Hoarding, now this disorder or this behavior is now conceptualized often as a different disorder, but sometimes people with OCD hoard things too. By hoarding, we mean you keep things and you're afraid to throw them away. So it can probably be seen both associated with OCD and independent and associated with hoarding disorder. And then internal repetition, you say something and then you have to say it over again, perhaps two, three, four times, or just adhering to certain rules or sequences. When you walk in the door, you have to do about six different things in a particular sequence. And you don't even really know why. It doesn't necessarily make sense. And it causes you a lot of distress if you can't do it. So you might've been thinking, as I was talking about the obsessions and the compulsions, well, they seem to go together. Well, a lot of times they do. And so here's an example of how certain obsessions may go with certain compulsions. So the cleanliness, contamination, obsessions may go with compulsions related to washing, bathing, cleaning. And I won't go through all of them, but you can kind of look and you can see that there's a logic to some of them. But sometimes there's not. And particularly when someone only has obsessions or they only have compulsions, sometimes there's obviously not a connection between the two because they actually don't have the two. Something else that I don't even think your book talks about too much, but it's worth mentioning is that OCD can affect people in a variety of ways, including their interpersonal relationships. And also interpersonal relationships can affect OCD or they can affect people with OCD. And it can really cause a lot of distress for family members or relationships like in couples. The dysfunctional relationship patterns can actually, as noted there, promote or maintain OCD so that you get in this sort of vicious cycle. Often people may do what they think is just the best thing to do, but it may sometimes not be the best thing to do. An example of this is what's sometimes called symptom accommodation, where you're basically sort of trying to help the person, but you make the symptoms probably persist, if not worse. So just a little bit more about symptom accommodation. As noted there, could be talking about friends or relatives participating in the loved one's rituals, doing it with them, or perhaps facilitating avoidance strategies. So people with OCD might avoid a lot of the things that trigger the obsessions and compulsions. And if the family members just allow them to avoid that, then they're never really confronting the problem. Sort of like with a phobia, if you allowed someone to just avoid ever confronting whatever it is that they're afraid of. Similarly, like assuming daily responsibilities. So imagine the person had cleaning rituals, and so they're supposed to wash the dishes. It takes them eight hours to do it because they have to do it in such a way where they repeat everything. And it takes so long that the family member goes, nevermind, I'll do it. Which you think is sort of solving the problem, but it allows the person to basically avoid and not have to confront the problem. And the last one there, perhaps resolving problems that have resulted from the person's obsessional fears or compulsive urges. So making it have less of an impact on the person, which you think is with good intentions. But when you do that, you're probably making it less likely that the person is going to actually do something about it. And because you allow the person to avoid having to deal with a lot of this stuff, you may prevent the natural extinction of the fear, which when we start talking about the theoretical models, make a little bit more sense. But the point is, you're basically allowing the person to stay the way they are rather than getting better. And this isn't just sort of anecdotal evidence. I mean, there's research showing that family accommodation may predict an attenuated, in other words, a less response to cognitive behavioral treatments for OCD. So often when you teach the people in their family about what the treatment's going to be like, you have to teach the family members to avoid doing certain things because it will sort of undermine the treatment. And here's just a table that has some examples of family accommodation. So again, it would depend on what the OCD symptom was. So if the person had contamination and washing symptoms, if the family member is doing, as I said just a minute ago, they're doing the washing or cleaning for the patient, sort of the patient avoids having to do it. Some of these things, you know, you really think it just seems like a normal thing to do, particularly the providing reassurance. So often people will be really unsure that, you know, is it okay if I do this? Is it going to hurt me if I do this? If I don't do this, is it going to be okay? And what they really need to learn is that, yes, it's going to be okay, but just by telling them that it sort of allows them to avoid having to deal with that uncertainty and tolerate it until it goes away on its own. So even as a therapist, you work with these people and you're exposing them to something and they'll ask you, well, you promised me it'll be okay. And you think you would say yes, but you actually say, no, I'm not going to promise that because you have to sort of learn for yourself that that fear actually goes away. And if I keep telling you everything's going to be okay, then it doesn't give you sort of a chance to learn that yourself. And you probably remember some of this, you know, from the snake video last week where the guy probably didn't say a whole lot during the procedure because he wasn't trying to just convince her that everything was okay. He was trying to let her see for herself that everything was okay. So there's some other examples there. But again, symptom accommodation or family accommodation is one of the interpersonal aspects of OCD. So relationship conflict is another interpersonal aspect of OCD. So relationship stress and conflict may play an important role maintaining OCD. Often couples or families where there's one or more individual with OCD report a variety of problems that lead to stress and conflict. Some of the things mentioned there. Some of these things that may lead to OCD maintenance, including poor problem-solving skills, hostility, criticism. And as what I said with symptom accommodation, this isn't just anecdotal. I mean, there is research showing that these kinds of things may predict the negative outcome, including premature treatment, discontinuation, and symptom relapse. So we've gone through this sort of general description. And now let's talk a bit about epidemiology. We used to think that OCD was a very rare condition, but now it's viewed as a relatively common disorder. It depends on what you're comparing it to. And I'll show you some data in just a moment. You would have seen some last week in comparison to other anxiety disorders. I'll come back to the same study. But prevalence rates in there, the figure cited there is probably based on some international data. Figures are fairly similar in Australia. And it can be a lifelong kind of problem. I mean, there's treatments that help quite a bit, but it may be something that to some degree persists as a lifetime sort of problem. Average age of onset. I mean, there is some data there. And it varies a little bit in terms of men versus women. So earlier onset for men and women later onset, different kinds of compulsions. So like cleaning compulsions seem to be a little bit more common among women than among men. This is the same study I was talking about from last week, where you looked at prevalence of anxiety disorders, and they still include OCD and PTSD in this table. Because remember, it used to be considered an anxiety disorder and it's still an anxiety-related disorder. So among these disorders, it's actually the least common, but still fairly common. So you see around 2% total and slightly higher rates for women than men. This particular study, remember, was 12-month prevalence rates. So lifetime prevalence would be slightly higher or significantly higher depending on the disorder. But for OCD, it's apparently slightly higher. So that's a brief little summary of some epidemiological data. In terms of etiology or causes, as with everything, we're not going to find a singular cause. And it's more important to look at different contributors, biological contributors, psychological, social. We'll touch on some of the highlights. Your book mentions a few things, a couple that I'll probably talk about, may not be in there. A couple of the sort of biological or neuropsychological models, your book does mention this first one, the idea that it results in some sort of failure of the inhibitory pathways in the brain to stop these behavioral macros in response to internal or external stimuli. These behavioral macros are like sets of behaviors related to a variety of things, including things like grooming and checking, which is an interesting suggestion. But as also pointed out by some other researchers, although you find differences between people with and without OCD, it's hard to say with certainty that whatever observed differences are causal or actually the result of having OCD. Another hypothesis you sometimes hear about has to do with serotonin, which is a neurotransmitter. And the idea is that something to do with OCD has to do with abnormalities in a specific neurotransmitter system having to do with serotonergic receptors. One of the lines of research associated with this is from the pharmacotherapy literature, suggesting that certain types of medications, the one that more selectively target serotonin, SSRIs in particular, are more effective than medications with other mechanisms in reducing OCD symptoms. However, there's other research that sort of, the findings are sort of incompatible with the serotonin hypothesis. And there's a general lack of logic associated with inferring etiology from response to treatment. We've talked about this. You'll see it associated with other disorders too, depressive disorders, psychotic disorders. The general idea is that you can't infer what causes something based on how it responds to treatment. A classic example of this is if you walk out the room and you hit your head on the door and you get a headache and then you say, well, I'm going to take some aspirin or norepinephrine or something like that. And the headache goes away. You can't infer that your headache was caused by a deficiency of aspirin or a deficiency of norepinephrine. It was caused by something else and the treatment had the effect, but that doesn't mean you can say a whole lot about the etiology. So it's a treatment to etiology fallacy. And it's something that, again, you'll see quite a bit in related to psychiatry. And it's one of the limitations of the serotonin hypothesis. So in terms of other models, there are quite a few factors related to cognition. I mean, this is a disorder where thinking plays a major part of it. But some researchers have looked into certain cognitive deficits. Like, for example, it seems obvious to at least consider when someone says, did I really turn the stove off or did I really turn the lights off or did I really lock the doors? Is it possible that they just can't remember? Like, you need to rule out that this is just a disorder of poor memory. Because if you can't remember very well, then it makes sense that you'd be checking things. And as people do get older, for example, with dementia, they may forget all sorts of stuff and they may have to check things. And it's because they really cannot remember. But at least based on the research that I'm aware of, researchers have found that there really isn't evidence to support the idea that, in general, people with OCD have a poor memory than people without OCD. In fact, they may actually have selectively better memory for OCD-related information than non-OCD-relevant information. So, stuff having to do with what they're worried about, they may actually remember it better. So, I mean, it doesn't mean that you can't rule that out for every single person. But in general, it appears that OCD is not really related to poor memory for the things that they obsess about. So, another somewhat similar area research has to do with the idea of reality monitoring, which is the ability to discriminate between memories of actual versus imagined events. So, you have people do stuff, or you have them imagine doing stuff, and then can they tell the difference? Because again, with someone with OCD, they could say, well, I can picture myself checking the stove or checking the door. Am I remembering actually doing it, or am I remembering just imagining that? So, it's a good question. But at least based on the research that I'm aware of, there haven't really been significant differences in reality monitoring between people with OCD and people that do not have OCD. So, good question, but no evidence that that's really what the problem is about. There's another area of cognitive research having to do with inhibitory deficits, the idea that people with OCD may have deficits in cognitive inhibition. In other words, the ability to dismiss extraneous mental stimuli, things that are unimportant. And here's an area where indeed they do seem to have some difficulty dismissing or forgetting negative material, particularly related to their obsessional fears and relative to other sorts of information. So, whatever that cognitive deficit is, it probably relates to some of the other cognitive mechanisms that I'll talk about in just a few minutes. So, before coming back to the cognitive models, let's talk a bit about behavioral models. And then we'll talk about sort of their integration also, like the cognitive behavioral model of OCD. What did I say last week associated with anxiety disorders was my favorite theory? At least, I should have said that because it is my favorite theory. That is Mauer's two-factor or two-stage theory of fear acquisition and maintenance. So, we definitely talked about this in the context of anxiety disorders. And we'll come back to it next week in the context of post-traumatic stress disorder and probably other times also. So, just as a quick review, the two factors or two stages are classical learning associated with the acquisition of fear. And then that's the first one. And then the second one is operant learning, particularly negative reinforcement, where the avoidance behavior is reinforced by reduction in anxiety, but it's a temporary reduction. And the problem with it is that it prevents natural extinction from happening. So, when the fear is acquired, it doesn't go away with exposure because the person avoids exposure or they do something to make it go away, in the case of OCD, engaging in the rituals to make it go away. So, this has been applied to OCD. The first stage, as noted there, is probably fallen out of favor as an explanation for OCD development. In other words, you sometimes find cases where they'll say this all started with some bad experience where they had some sort of real aversive traumatic experience that then led them to be triggered when reminded of that and have to engage in the rituals to make it go away. But more often than not, they don't. They don't report an initial learning experience. So, again, the first part of Maurer's two-factor theory is less relevant to OCD than it is for perhaps other anxiety disorders. But the second part is very relevant. So, the negative reinforcement associated with the compulsions, the rituals, if we want to call them that, is still viewed as a major factor in terms of understanding the maintenance of OCD. And the treatments that have come from that are based on the idea that that negative reinforcement is something you need to intervene to do something about it. So, cognitive factors, let's talk about them again. Before we talk about cognitive deficits, here we're talking about something slightly different. Basically, the idea is that intrusive thoughts are relatively common, relatively universal, as noted there, going back to a fairly famous study by Rockman in the 70s, showing that the kinds of obsessive thoughts or the kinds of thoughts that people have associated with OCD occur in people who don't have OCD also. And if you think about your own experience, I mean, a lot of the thoughts that we have talked about you may have in passing, but if you don't have OCD, you don't make a big deal of it. You just sort of say, oh, well, that's just a thought. I'm not going to act on that thought, for example, or it doesn't mean anything about me. Whereas people with OCD are more worried that they're going to act on them or that it tells you something about them, like it makes them a bad person to have a particular kind of thought. So because of that, for a variety of reasons, some of which I'll get to in just a minute, people with OCD try not to have the thoughts. They try to suppress them or they try to do something else to make them go away. And what we also seem to know is that trying to suppress thoughts may actually make them worse. And that may actually be the main problem associated with OCD. If you think about it, there's a famous study, you probably learned about it in either like an intro class or a cognitive class. The quote there, try to pose for yourself this task, not to think of a polar bear. And you'll see that the curse thing will come to mind every minute. So in other words, you tell yourself not to think of something and what basically ends up happening is you can think of nothing but that. So again, the idea here is the presence of the obsessions may not be so much the problem as it is trying to make them go away. Now there has been some follow-up research suggesting that there may be some differences in terms of the types of thoughts that people have, but it's still a fairly robust finding that intrusive thoughts are relatively common in the general population. But again, it's not everybody tries to suppress them. Why do people with OCD try to suppress them? There's other research sort of on the different types of dysfunctional assumptions or cognitive distortions. Remember last week, I think, or maybe even the week before, we talked about Beck's theory of psychopathology or depression, sometimes more specifically, and how different types of thoughts may be associated with different types of disorders. We learned a little bit about that last week also. Well, there's some research to suggest that there's specific types of thoughts associated with OCD. And I don't mean by intrusive thoughts, I mean thoughts about thoughts or beliefs about thoughts. For example, the idea that having a thought about an action is like performing the action. So in other words, if you think you have this thought about hurting somebody, it's like you actually did hurt somebody. Sometimes this is referred to as thought-action fusion, where you're sort of fusing the idea of a thought with actually doing something. Another one, failing to prevent harm to the self or other is the same as having caused the harm in the first place. So if you had a chance to do something that could keep someone from getting hurt and you didn't, your family or anybody, then it's your fault. You basically caused it to happen. Related to that, responsibility is not attenuated by other factors. For example, low probability, even those like one in a million chances something could have happened, it's your fault. You're still responsible for it. And this one, which, if you think about it, if you really believe this, you would have a hard time when you had such thoughts associated with OCD. Not neutralizing when an intrusion has occurred is similar or equivalent to seeking or wanting the harm involved in that intrusion to actually happen. So in other words, like if you had this thought of harming another person and you didn't make that go away, you would interpret that as meaning that you want it to happen, even if it's harming your family member or your child or something like that. It basically would make you a bad person. So you can see why if people believe these things, they're going to not want to have the kind of thoughts associated with OCD and they're going to want to do all sorts of stuff to try to make them go away. And last one, that one should and can exercise control over one's thoughts. I mean, this kind of all the above kind of leads up to this one. And the second part, we probably know is really you can't, right? I've just shown you that if you try not to think of stuff, it's more likely that you will think of it. The should part is different. It's more of a moral thing that you shouldn't have these kinds of thoughts. And many people are brought up being taught that. I don't want to get into religion too much, but some religions say having a thought is as bad as actually doing it. And so sometimes people come from these very sort of moralistic backgrounds. And again, having the thought to them is just as bad as actually doing it. And so they don't want to have the thought. So they engage in all these other kinds of things to make the thoughts go away. So as we transition into start talking about treatment, keep in mind what I just said, both in terms of the cognitive factors and also the earlier behavioral models, because basically treatments are based on those understandings of OCD, at least the psychological treatments, the cognitive behavioral treatments are. And in general, that's probably viewed as the treatment of choice, where there's the most empirical support at least for two interventions, which can be done together or can be done separately. Sometimes they're studied separately. That's the first one, exposure and response prevention, which is largely a behavioral intervention. And then the second one, cognitive therapy, which as the name implies, is largely a cognitive intervention. Again, sometimes they can be done together and there's times when you really need to do one rather than the other, which I'll get to in a moment. Medications, I mean, we talked about SSRIs being used before and they are used sometimes, but as noted there, some of the data suggests that, excuse me, perhaps 40 to 60% of people with the disorder seems to benefit from the medication. We'd ideally like something higher than that. The psychological interventions are not perfect either. And we'll talk about some of those data shortly. So in terms of treatment, particularly the cognitive behavioral treatments are closely connected to the cognitive behavioral models. And so for treatment to be effective, a couple of things need to happen, at least according to these models. One is correction of the maladaptive beliefs and appraisals that lead to the obsessional fear. So the kinds of cognitive phenomena we were just talking about, about the importance of thoughts and the importance of being able to control them and thought-action fusion, all those things need to be addressed. And then also what needs to happen is we need to terminate the avoidance and compulsive rituals that prevent the self-correction of maladaptive beliefs and extinction of anxiety. In other words, if people didn't engage in those rituals, these cognitive phenomena might actually correct themselves. The rituals are preventing them from ever learning that. Now, how you go about doing this depends on the nature of the therapy. Sometimes you can get cognitive change through behavior change or emotional experiences like exposure. Other times you need to, or other times you do directly try to challenge the cognitive phenomenon. So just a little bit more about the two cognitive behavioral treatments that I've alluded to and discussed in your text. First, exposure plus either ritual or response prevention. They basically mean the same thing. And basically that's what you do. You expose people to something that triggers their obsessions and you prevent their response, which is their compulsion. There is a lot of evidence supporting this, probably the most empirically supported treatment. However, it's not easy to do. It's considered aversive by many. I'll give you some examples shortly and you'll see what I mean. It's also either hard or impossible to do if someone only has obsessions. Remember, you could be diagnosed with the OCD with having obsessions, but not compulsions. And so if the person does have compulsions, there's nothing really to prevent. In those cases, or if there's just a reason to do it anyways, cognitive therapy might be used where you use more cognitive techniques to directly challenge beliefs about the anticipated consequences of not engaging in compulsions. It often may involve exposure also because one way to challenge a belief is to test it out. You say, well, let's see what happens. So, they're not totally independent of one or another. So, just a little bit more about exposure and response prevention on this slide. It's a technique or set of techniques, as I've said, derived from the cognitive behavioral theoretical model for OCD. You basically have the person confront the stimuli that provoke the fear. So, it's tailored to that individual. So, if someone has contamination fears, it might be exposing them to dirt or whatever it is that they're worried about contamination, but at the same time, objectively pose a low risk. So, you're not going to have someone go out and do something that would be really dangerous. Now that during the procedure, they may keep asking you, now, is this going to be dangerous? Now, at the beginning, you would explain that to them, but during the procedure, you wouldn't keep answering them because remember that giving that reassurance is kind of undermining the particular treatment. So, this can be done in person or it can be done imagined as noted there. So, some things you actually can't do probably in person. If you can't, you do it imaginatively. And this provokes a lot of anxiety, but the person's encouraged to not avoid it, to basically sort of sit with the feeling until it begins to subside on its own. So, when doing this over time, the anxiety or other negative feelings sort of naturally subsides, possibly through habituation, although we don't really know exactly why. There's actually a reading that I made available as an optional reading that goes into much more detail about why exposure-based therapies work. And in the tutorial that's happening this week, there'll be some discussion of that in the context of phobias. It may be habituation, it may be extinction, but it may be more of a cognitive mechanism. So, we know that it does happen, but we can't say with certainty why. The other component, the response prevention component, what that is, it's refraining from the compulsive rituals and other subtle avoidance behaviors, which would include things like asking for reassurance, just not thinking about it, all that sort of stuff that allows the person to sort of escape from the obsessive fear. And you're trying to stop them doing those things so that they actually learn that the anxiety and other negative emotions do subside over time. It is important that they do both the exposure and response prevention if they have responses. Again, you can't do it if they don't. Because if you only do exposure but you don't do response prevention, then they will simply do the response and it will allow them to basically reinforce the behavior by allowing the anxiety to go down. And they will never learn that it would have gone down on its own if they had not engaged in the behavior. So, there's actually research showing that both components are necessary. So, just about the delivery of exposure and response prevention, some of the practical things are on this slide, because it can vary quite widely. Although in general, it's a fairly intensive sort of treatment. So, as you see there, it might be, notice the part about daily or twice weekly. I mean, 15 sessions that are, you're doing it either every day or at least a few times a week. And sometimes you can't do that. I mean, there may just be logistical reasons why it can't be done. But if you really just sort of spread it out to like 50-minute sessions every couple weeks, it's probably not going to work for exposure and response prevention. Notice also, they often have to last a good while. So, you know, 90 minutes or more, you can't just do this quickly and then stop it while the person's still experiencing high levels of anxiety, because then you may have basically made the problem worse. Typically, you know, it begins with assessment where you measure all the stuff, the level of obsessions, compulsions, take that information and plan some sort of specific exposure exercises that, as I said, might be in vivo, might be imaginal. And you can sort of vary, you can do a hierarchical sort of thing where you start sort of low and move your way up. Or you can start higher up. I mean, it's really kind of up to you and the client to discuss how the person wants to handle it. Do they want to do it sort of starting with the more difficult stuff and perhaps making it a shorter treatment? Or do they feel they need to work their way up from how things that produce less amounts of distress or anxiety? And, you know, with sort of an individualized treatment approach, you do it, collect data to see how things are working and modify it if necessary. So, in this slide, just some data regarding the efficacy of or effectiveness of exposure and response prevention. I mean, it's been studied a lot, as I've said, and in general, you can make the statement that those who complete this intervention, which is important because if they drop out, it's a different story, but they complete it, they typically attain clinically significant and durable improvement. It doesn't mean that the problem is completely gone, but it means they're significantly improved. Some of the rates somewhere, perhaps 50 to 70% in these studies, in effectiveness studies, some were 80% of those who complete, again, achieve clinically significant improvement. However, as I've said, it's not perfect. And although it works for a lot of people, there's a percentage who don't respond and also a percentage who drop out. And then probably another group of people from the beginning, as I said, who can't do it because they don't have identifiable compulsions that you could try to stop, you know, in the exposure and response prevention. So, often for those who can't do exposure and response prevention because they don't have identifiable compulsions, or they don't want to do it, or there are logistical reasons, like you don't have the time to be able to put in to do it correctly. Those are all reasons why you might use cognitive therapy. So, with cognitive therapy, the therapist, as noted there, prevents the rationale based on sort of what we were talking about earlier, that intrusive thoughts are basically normal and the thoughts themselves are not harmful and they're not meaningful in the way that the person thinks that they are. The goal is still to affect change, even though you're not doing it behaviorally. So, you want to sort of reduce the need for the compulsive rituals rather than saying you just can't do them during the therapy itself. Most of what you're doing is helping challenge correct dysfunctional thinking and the behavioral responses should follow from that. But again, you're not directly doing it as you would do it in the behavioral intervention. A variety of cognitive therapy techniques that we'll probably come back to also, like we talk about depressive disorders, but didactic presentation of educational materials, Socratic dialogue, where you sort of try to lead the person to the correct answer, cognitive restructuring, helping identify the thinking errors and learning to challenge them, all the kind of things that you try to do. There's an example from your textbook where it starts with the example, the person says they're worried that they would have caught something from touching a rubbish bin and you ask them, what do you think the probability of that is? And they give you some really high probability. Then you say, well, look, let's just think about what are all the things that have to happen for that result to actually first, you would have had to actually, you know, touch the bin. Then there has to be germs present on it. And then those germs have to be capable of whatever it is, you know, you've read the example and then you have them say, well, okay, what are the actual probability of each of those steps? And you, you know, you multiply those out. And by the end, instead of having a very high probability, you have a very low probability. So trying to get them to think more logically about the kinds of thoughts that they're having. And again, this is something that's used in other forms of treatments or cognitive therapy for other kinds of disorders too. But this is an example of how it would be used for obsessive compulsive disorder. Now there are studies actually comparing cognitive therapy and exposure and response prevention. And sometimes they're found to be relatively equivalent, although there are methodological limitations that make it hard to say for sure. They sometimes may work together in certain ways. So for example, as noted there, including cognitive therapy was helpful in reducing the dropout rate, exposure and response prevention. So there may be reasons to incorporate cognitive techniques alongside the more behavioral approaches. And remember that there's some people that they cannot, or just will not do exposure and response prevention. So you need to do something else. Often cognitive therapy, or sometimes if you really go back to the discussion earlier around the interpersonal factors, sometimes that's the most significant problem. And you may need to do targeting the interpersonal problems rather than the OCD specifically. And in doing so, you may actually indirectly affect the OCD. Okay. So that ends our discussion of obsessive compulsive disorder specifically. Now we're back to the other obsessive compulsive related disorders. So this is the list from above. And for the remainder of this, let's briefly discuss these four disorders. And with the most emphasis on body dysmorphic disorder. All right. So let's start with that one, body dysmorphic disorder. And first, let's think about why it's in this category. What does it have in common with OCD? Well, as noted there, they can both involve distressing thoughts about one's appearance and repeated checking might be observed in both disorders. However, with BDD, it's limited just to their appearance. Whereas individuals with OCD may have other kinds of obsessions and other kinds of compulsions. Another similarity is that similar psychological treatments can be used for both conditions, particularly exposure and response prevention. So there are some similarities, but there's also quite a few differences. And as we will see later in the course, one can make an argument that body dysmorphic disorder shares many similarities with the eating disorders, even though it's less about eating behavior, but they still share that body image component. So here are the full DSM criteria. As noted there, preoccupation with one or more perceived defects or flaws in physical appearance. Most importantly, that are not observed or appear slight to others. So it has to be some sort of misperception, either complete. And sometimes you'll look at people that have BDD and say, I don't see anything that you're talking about. Or perhaps it could be something that is there, but it's not to the degree that they think it is. So that's the A criterion. The B criterion, which is, again, sort of why it's in the OC-related disorders. At some point, the person's engaged in repetitive behaviors. So this is the kind of rituals of mirror checking, excessive grooming, skin picking, or mental acts. So they're either doing motoric sort of rituals or mental sort of rituals. The C criterion, as with all disorders, it has to cause clinically significant distress or impairment in one of those areas. And what a lot of people don't realize is this disorder really can cause extreme significant impairment. They think it may just be someone who's just sort of unhappy with their appearance, but actually it can be very extreme. And you can have suicidal behavior associated with it, or people engaging in sort of self-plastic surgery, cosmetic surgery, where they try to alter their appearance themselves. I mean, very extreme sorts of things. The last criterion there is largely to differentiate it from an eating disorder. So we're talking about concerns about their body, but it's not just someone who is concerned with being overweight or something like that, which would perhaps be more classed as an eating disorder. However, there is clearly a major overlap between this and the eating disorders. And many people have argued that it's really sort of a variant of a body image sort of disorder. Note there at the end, with variable degree of insight. So remember I said with OCD, you can specify the level of insight ranging from very good to basically absent or delusional. So the same thing can apply here. And there's also a variant of this called muscle dysmorphia that we're going to get to a little bit more in just a minute. So you can specify, is it body dysmorphic disorder with muscle dysmorphia or not? So at this point, I'm going to try to show you a video, just part of the video. It doesn't always work correctly. And we'll see the entire video at some point in one of our practicals. But I want to give you just a couple minutes of the beginning of it, and then we'll talk about it. So hopefully you're able to see that. And just to sort of make a point that, again, this is something that can affect people quite significantly. And it is quite a distortion. And there is quite a connection with eating disorders. I mean, sort of the whole idea of looking in the mirror and seeing someone quite different than how other people see you is something you often think of when you think of someone with an eating disorder. And again, we're talking about something that is largely imagined or exaggerated. Because if you look at all four of the people that we saw, you don't have the reaction to their appearance that they do, right? So we're talking about some sort of body image-related condition. And again, we'll come back to that. You'll get to see the whole video at some point in time in the future. Let's keep talking about the disorder though, and I'll also show you another video shortly. Just some other features of BDD. It was previously known as dysmorphophobia. So that was a term you can find in the literature before the term body dysmorphic disorder was coined. And again, it's sort of a preoccupation with some sort of imagined defect in appearance. Interestingly, their relationship with mirrors can be one way or the other. Like you'll find that some people with the disorder will have sort of an obsession with mirrors where every time they see one, they'll have to look at themselves. Even things like walking down the street and looking in the reflection in car windows or things like that. So that's one extreme. The other extreme is that they will completely avoid mirrors. Like they'll say they never look at a mirror and they would have to avoid looking at the reflection in a car window or water or anything like that. So again, it's one extreme or the other, which also somewhat parallels what you see with people with eating disorders, where sometimes they may look at themselves frequently. Other times they may avoid mirrors. Similarly, with scales with people with eating disorders, sometimes they may weigh themselves repeatedly. Other times they may completely avoid them. So I'm making a case that there's quite a few similarities between VDD and eating disorders. Although, remember, we're still talking about a disorder that's in the obsessive compulsive related disorders section of the DSM. The other things there I've mentioned, and I think were mentioned even in the brief clip that you saw, if not, it's somewhere in the video, that suicidal ideation and behavior are quite common. They may also display things like ideas of reference for the imagined defect, which ideas of reference are like where you take things that are basically random and you assume they have some special significance for you. And they can range from just ideas of reference to extreme delusions of reference. So for example, if someone walked into a room and they heard laughing, they would immediately think, well, they're laughing at my physical appearance, as opposed to it could just be anything. And if they were certain of it, then again, it could be a delusion of reference as opposed to just idea of reference. So just some facts and statistics about VDD, probably more common than was previously thought, perhaps underdiagnosed. A lot of people may go somewhere else like rather than seeking psychological treatment because they don't realize that it's a psychological kind of phenomenon. Prevalence rates may be somewhere around 2.5% noted there, perhaps similar numbers for males and females, but maybe different focus. The third bullet point gets at what I was saying above that they may go to see a cosmetic surgeon. And so there are some data suggesting that a fairly large percent noted there, maybe up to 15% of those seeking cosmetic surgery may meet the criteria for VDD. One of my students, even a few years ago as an honors project, surveyed cosmetic surgeons in different countries to try to get it how commonly they were screening for this, because if it's really that common and it really is a distortion, like there's not a real defect, why should they be actually offering someone cosmetic surgery if they don't need it? And there's even research suggesting that it doesn't make the problem better. In fact, it might make it worse. But anyway, some of the other stats there, onset, perhaps early 20s, often these people remain single as noted, may seek out plastic surgeons. I don't mean for marriage. I mean to treat the problem, but that's really not the appropriate treatment for the problem and may run a lifelong course if untreated. Areas of concern, they might have a variety or it might be one in particular. These are some of the common ones. And again, there may be some variability in terms of men versus women. Stomach also, we're talking about, it can't just be, you think you're too fat because that might be more consistent with an eating disorder, but it could be something else about the appearance of the stomach that would qualify for BDD. Now, I mentioned earlier that there's a subset of people with BDD who might meet the criteria for something called muscle dysmorphia. So, let's talk a little about that in a little bit more detail. This is, again, viewed as a variant of BDD, but it's defined as basically a pathological obsession with not being muscular enough. Now, this is not meaning that someone who wants to be very muscular has muscle dysmorphia. The idea is that there is, again, some sort of body image disturbance where they see themselves differently than they probably actually are. So, they might already be very muscular, but they perceive themselves sort of as weak and puny. These are actually terms that they may use. There's a lot of names that you hear about this being called. Some of them are sort of just plays on words. The one I have there is one that you'll sometimes hear, which is obviously a play on the word anorexia, bigorexia, the idea that they already are big, but they want to be bigger. And so, bigorexia. Now, I'm going to try to show you another clip here also, which is an interview on a news program with a psychologist talking about muscle dysmorphia. So, again, hopefully this will work. Let me give it a try, and then we'll talk about it. Yeah. So, interesting interview. The questions asked by the people doing the interviewing are not always the best, but the psychologist gave some pretty good answers. And then the people being interviewed in the video made some interesting comments. They knew what we were talking about. They knew when they use that word, they go, yeah, we have these kinds of people in the gym. And the first guy that they interviewed, he's obviously a bodybuilder, and we're not saying that he has the problem, but he's aware of people that do. And they also talked about some of the things that people can do in terms of harmful sorts of things like anabolic steroids and so forth. Now, they asked the psychologist, you know, where do you sort of draw the line between what's normal and what's not normal, what's healthy and what's not healthy? And he did say one thing that I agree with, that was the part about the impairment that it causes in people's lives. And that's one of the general definitions of a disorder. The thing he didn't mention though, which I think you can clearly see though, and we've been talking about is the sort of body image component, that it's not based on reality and that there's some sort of distortion in terms of how people see themselves. What else here? We mentioned that may be associated with anabolic steroid use. So, that's one of the sort of parallels with something like anorexia, where they may use other kinds of drugs that are very harmful to them. This particular disorder, more common in men, but there are reported cases in women too. I think Stuart Murray mentioned that also, and there definitely are some reported cases. In terms of causes and treatments, we have limited data on both of these issues. As noted there, the disorder shares many similarities with both OCD and anorexia nervosa. So, perhaps our understanding of those disorders may help better understand it. And by it, I'm talking about BDD broadly, not specifically muscle dysmorphia. Some of the treatments have been borrowed from the other disorders, particularly OCD. So, some of the medications that have been used for OCD, SSRIs, and the exposure and response prevention has been used with BDD. So, by that, I mean, you sort of expose the person typically to things like a mirror, you know, where it triggers the need to engage in whatever kind of ritual it may be, for example, skin picking or something like that. And then the person is not supposed to do that, and they're supposed to do it until the anxiety diminishes. So, it's not a perfect sort of translation from OCD, but that is how it's been used. And as noted there at the last, I've talked about how cosmetic surgery, plastic surgery is where these people often turn, but it does not seem to help. And it may backfire. I mean, in reviewing some of this literature, I even found cases where the person became violent after having cosmetic surgery because they were angry at the physician. So, physicians actually should be very careful about screening for this rather than just doing it because the person wants the surgery and is willing to pay for it. All right. So, that concludes our discussion of body dysmorphic disorder. So, we've talked about OCD and BDD, and both of those in some degree of detail. These last few here, I'm not going to go into much detail because your text doesn't, and we have limited information about both of them. But at the very least, you should understand what they are. So, hoarding disorder is something that prior to the DSM-5 was not in there as a disorder in and of itself. It was viewed as being a variant of OCD. But if you think about it, it's really quite different in some ways. And what we're talking about here is when people have thoughts about acquiring and maintaining stuff, but they don't really have particularly intrusive, unwanted thoughts and maybe actually have positive or neutral emotions associated with it. So, they don't really meet the criteria for obsessions. The problem with the disorder, the problem of the disorder, I guess, is the persistent difficulty in discarding the stuff and the high level of distress associated with removing the item. So, they avoid removing it, and that's negatively reinforced, and the behavior does get worse. And, of course, you've seen examples of this. I never watched those shows, but I think there's a show on TV specifically about this. And, you know, you see many cases where their house is completely full of something. And it can really cause significant problems. As noted there in that third slide, it can be risk to the health and safety. You know, you can have like a fire started in the house because they've hoarded newspapers forever, or they might have, you know, animals and they've let the feces accumulated in the house and all sorts of stuff. So, it can be a significant problem. As with the other disorders I've said, you can specify the level of insight. And we do have some preliminary data there on prevalence, but it hasn't obviously been studied to the same degree as some of these other disorders. So, the last two of the OCRDs, as I'm calling them, both have somewhat interesting names. Trichotillomania is the first. And that name has actually been around for a good while. It wasn't put into this category until the DSM-5. This also is known as a hair pulling disorder. So, as you might can guess from that name, at least the hair pulling disorder name, it is characterized by recurrently pulling out one's hair to the point where it has to result in noticeable hair loss. People stop or they try to stop the pulling and feel like they can't do it, they can't stop. It has to cause significant distress or impairment as any disorder does. And it's not due to a medical condition. I'm not exactly sure what medical condition could cause that, but I'm sure there's something. Probably more importantly, it's not better explained by another mental disorder. So, like there are other disorders where people might engage in sort of self-injurious behaviors, certain personality disorders we'll get to later in the term. I've worked with people that were like trauma survivors that might pull their hair out at times. And allegedly, it's not that. So, you've ruled out all those sorts of things. It has to be basically the hair pulling behavior and nothing else, which might actually raise questions. If you really go back and think of things we talked about in week one about the general definition of a mental disorder, remember the idea that it was supposed to be a syndrome, which is a group of signs and symptoms, not just one thing, whereas these last two disorders seem to be more like one thing. But it is in the DSM. It has been around for a while, and there is some degree of research on it. So, some of the few things that we do know about it on this slide, I mean, the urge to remove the hair is often associated with anxiety. We do have some sort of prevalence data and also seems to be more common among females and males. But again, one of the disorders that could certainly use more research, including does it meet the full criteria for a disorder. Perhaps you could say the same thing about this last one, which is excoriation or skin picking disorder. Sometimes this is abbreviated SPD. And this is, again, allegedly the one sort of behavior, not part of something else. So, remember with BDD, we talked about someone might engage in skin picking because of their physical appearance concerns. And if that's what this was, then this wouldn't be a separate disorder. So, as with trichotillomania, you have to rule out that it's not caused by another, well, first of all, by a physical condition, medical condition, and it's not better explained by another mental disorder. So, if they were doing it as part of BDD, it would not be this. And so, again, to me, it comes down to, we're talking about a single sort of behavior. Does that meet the full criteria for a syndrome, which is supposed to be a syndrome to be a disorder? I don't know. It's been around, again, for a while with some limited research on it. But to me, I question, does it meet that full definition of a disorder? So, here's a little bit that we do know about excoriation. It's often comorbid with OCD and trichotillomania, which to me raises additional concerns about what I was just saying about, is it really a separate disorder if it's primarily occurring or at least often occurring with something else? Some prevalence data there, not extremely rare, but I'm not sure how many prevalence studies have actually been done. At least we have a little bit of evidence in terms of the male-female ratio there. But both of these disorders need more research. So, in terms of treatments for the OCRDs, we obviously have the most research on OCD, followed by second most on BDD, and much less on the other ones that we've been talking about. However, probably the procedures that have been used have sort of been borrowed from what we know about OCD and BDD to some degree. So, people would often try some of the exposure and response prevention approaches we've talked about, cognitive therapy. But I'm not particularly aware of any randomized controlled trials for either of these last two disorders. Medications are probably sort of tried as a hit or miss, and SSRIs or similar types of medications would be tried. But again, we need more research on both of these. Now, I believe that's the last slide related to the obsessive-compulsive related disorders. I'm going to throw one more disorder in here, just one more for the road. Because you might have heard of this, and then you might be going, well, wait a minute, what's that if we've been talking about OCD? So, there is a disorder called obsessive-compulsive personality disorder. So, not obsessive-compulsive disorder, but personality disorder. And as the name implies, it is a type of personality disorder. So, we will come back to it when we talk about personality disorders. But it's worth just contrasting how it differs with obsessive-compulsive disorder, just in case you get confused. Because it's a personality disorder, it's focused more on personality traits. So, it's defined by traits such as perfectionism, inflexibility, rigidity, another name for that, and a need for control that may negatively affect interpersonal relationships. Often, these relationships are what brings the person into therapy. They may often maintain strict principles and be very intolerant of other people who don't conform to their standards. They can be very hard to deal with. There may be some similarities between OCD and OCPD that, for example, like making lists and arranging things, things have to be a certain way. But there's a pretty fundamental difference between OCD and OCD. And that is what I have here, the idea that the experience of people with OCPD is more ego-syntonic. That's a term, it really goes back to a sort of psychodynamic way of thinking. And ego-syntonic means it's sort of part of them. It's part of who they are. And they generally consider their behaviors and urges as rational and appropriate. Whereas people with OCD, typically, their experience is more ego-dystonic. So, it's not, at least for most of them, it's not something that they see as part of them. They don't want to be this way. They don't like being this way. And so, they want to change. So, with a few exceptions, that's one of the primary distinguishing features between the two disorders. And when I say with a few exceptions, I mean, there's probably, for example, someone who's OCD with zero insight, it may appear to be more ego-syntonic. But for the vast majority of people with OCD, it's not. Even though these are different disorders, in theory, they can co-occur. There's a certain subset of people with OCD who would meet the criteria for OCPD. And they're probably commonly confused, like in the popular media and literature, you might see people talking about someone being very OCD or very obsessive-compulsive. And they might really be talking about obsessive-compulsive personality features rather than obsessive-compulsive disorder features. And just last stat there, a certain percentage of people with OCD may actually display some of the symptoms of OCPD, but not necessarily meet the full criteria for the disorder. And if someone does happen to have both, there's some research suggesting that those that are comorbid have a poor outcome for OCD than someone with OCD who did not have OCPD, which makes some sense given that people with OCD are generally rigid. And the more rigid you are, probably the harder it is to change. So, there's some logic there. So, I believe that is the last that I plan to say on this topic. If you have any questions, post them online in the questions about the course forum. Don't forget also that you have a tutorial this week that will be on exposure therapy for anxiety disorders, specifically focusing on phobias. But the therapy actually has a lot in common with exposure therapies for OCD also. And then finally, don't forget that the first quiz is occurring this week. That begins on Thursday at the end of the day, and you have until the end of the day on Friday. And it will cover everything from the first three weeks of the course, including the first three chapters, any of the lecture material, and any of the tutorial material.

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