Lecture 11 - Pre-occupation and obsession II PDF

Obsessive-Compulsive and Related Disorders Geneviève Trudel, PhD Candidate University of Ottawa Midterm I Topics Covered : • Week 1 : • Introduction • Week 2 : • Historical Perspectives • Integrative Approach I • Week 3 : • Integrative Approach II • Assessment/Diagnosis • Week 4 : • Mood Disord...

Obsessive-Compulsive and Related Disorders Geneviève Trudel, PhD Candidate University of Ottawa Midterm I Topics Covered : • Week 1 : • Introduction • Week 2 : • Historical Perspectives • Integrative Approach I • Week 3 : • Integrative Approach II • Assessment/Diagnosis • Week 4 : • Mood Disorder I • Mood Disorder II • Week 5 : • Anxiety Disorders I • Anxiety Disorders II Outline • Obsessive-Compulsive and Related Disorders • Obsessive-Compulsive Disorder • Body dysmorphic disorder • Hoarding • Trichotillomania and excoriation disorders • Somatic symptom and related disorders • Somatic symptom disorder • Illness anxiety disorder • Psychological factors affecting medical condition • Conversion disorder • Factitious disorder DSM-5 Criteria: Obsessive-Compulsive Disorder • Presence of obsessions, compulsions, or both: --- Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). --- Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. • B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (NOCD, 2023) Obsession : ”My cat will die” Compulsion: Check on cat, ask partner for reassurance, search for signs of illness in cats on the internet, check cat’s heart rate Avoidance: - Tries to stay at home - Avoids travelling - Puts camera in the house to check on cat while at work OCD as a brain disorder • Intrusive thoughts and occasionally engaging in ritualistic behaviors can be normal. • However, OCD is believed to be a neurological problem characterized by low serotonin. • OCD brains have difficulty differentiating between important information and intrusive thoughts. As such, the brain tries to act on all the thoughts. (Schwartz, 1996; International OCD foundation, 2023) OCD Insight 1. With good or fair insight: • The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true. 2. With poor insight: • The individual thinks obsessive-compulsive disorder beliefs are probably true. 3. With absent insight/delusional beliefs: • The individual is completely convinced that obsessive-compulsive disorder beliefs are true. Prevalence Prevalence • •• • • • • • •• •• •• Approximately 1% of general population in a given year Approximately 1% ofto general Similar female malepopulation ratio in a given year Similar female to male ratio, but males start earlier (onset is early However, in childhood there are more boys than girls with OCD adolescence to mid-20s), and some evidence for difference in themes adolescence to mid-20s Chronic if untreated Chronic if with untreated Most people OCD have good insight Similar cultures Most across people with OCD have good insight •Similar Comorbidity: across cultures • 76% lifetime diagnosis of anxiety disorder (before OCD) • • 41% lifetime diagnosis of major depressive disorder (after OCD) • 30% lifetime diagnosis of tic disorder Comorbidity: • 76% lifetime diagnosis of anxiety disorder (before OCD) • 41% lifetime diagnosis of major depressive disorder (after OCD) • 30% lifetime diagnosis of tic disorder What doesn’t work • Engaging with the content of the obsessions • Providing reassurance that the feared outcome will never occur • Distraction alone (e.g., relaxation breathing) • Telling people to just think about something else Body Dysmorphic Disorder DSM-5 Criteria: Body Dysmorphic Disorder A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder. “There’s something wrong with my body” Compulsions Anxiety down Anxiety up Obsessions Mirror checking, reassurance-seeking, excessive grooming Prevalence • Most people fixate on their appearance some of the time • Overall, about 1-2% of individuals in community samples • The risk of suicide is high amongst people with BDD (21-28% have attempted suicide) • BDD is over-representative in certain populations (DSM-5, 2013): • • • • • • 2-13% percent of student samples meet criteria for BDD 9%–15% among dermatology patients, 7%–8% among U.S. cosmetic surgery patients, 3%–16% among international cosmetic surgery patients (most studies), 8% among adult orthodontia patients, 10% among patients presenting for oral or maxillofacial surgery Insight into obsessions (good/fair; poor; absent/ delusional) Muscle dysmorphia BDD Specifiers Hoarding Disorder DSM-5 Criteria: Hoarding Disorder A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). • Specifier • With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space • Insight (good/fair, poor, absent/delusional) https://www.youtube.com/watch?v=M6EU33oK6hg Hoarding disorder • 2-5% (nearly double the rates of OCD) • Although only a tiny percentage of fires in residences occur in the homes of individuals who hoard (<1%), these fires account for 24 percent of all fire-related fatalities • Less evidence on effective treatments for hoarding disorder (some promising research for CBT) • Example: teaching clients to assign different values to objects and to reduce anxiety about throwing away items that are somewhat less valued • Home cleaning a necessary (though insufficient) part of treatment Compulsive-pulling disorders Excoriation disorder (skinExcoriation disorder (skinpicking) Excoriation disorder (skinpicking) picking) Trichotillomania (compulsive hairpulling Trichotillomania (compulsive hairpulling Many reasons for pulling (e.g. tension relief). Habit reversal training focuses on understanding the cue for pulling and implementing a behaviour that is incompatible (e.g sitting on your hands) How would you treat Obsessive-Compulsive and Related Disorders ? Exposure and Response Prevention Somatic symptom and related disorders Somatic symptom disorder Conversion Disorder Illness anxiety disorder Malingering Psychological factors affecting medical condition Factitious Disorder College of Psychologists of Ontario: Health Psychology is the application of psychological knowledge and skills to the promotion and maintenance of health, the prevention and treatment of illness, and the identification of determinants of health and illness. • Types of concerns in health psychology • • • • • • • • Chronic pain Diabetes management Bariatric surgery and weight management Epilepsy Multiple sclerosis Cancer Infectious diseases Chronic fatigue • Types of interventions in health psychology • Medication/treatment adherence • Co-morbid mental disorders with specific illness • Managing psychological factors (e.g. negative emotions) related to illness and loss of ability Somatic symptom disorder Illness anxiety disorder Psychological factors affecting medical condition Distress and dysfunction associated with medical symptoms Somatic symptom disorder A. One or more somatic symptoms that are distressing or result in significant disruption of daily life. B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: I. Disproportionate and persistent thoughts about the seriousness of one’s symptoms. II. Persistently high level of anxiety about health or symptoms. III. Excessive time and energy devoted to these symptoms or health concerns. C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). • The symptoms may or may not be associated with another medical condition. The diagnoses of somatic symptom disorder and a concurrent medical illness are not mutually exclusive, and these frequently occur together Illness anxiety disorder • Formerly “hypochondriasis” A. Preoccupation with having or acquiring a serious illness. B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate. C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals) • Specifiers • Care-seeking type • Care-avoidant type Somatic symptom disorder • One or more somatic symptoms that are distressing or result in significant disruption of daily life. • The symptoms may or may not be associated with another medical condition Illness anxiety disorder • Somatic symptoms are not present or, if present, are only mild in intensity. The individual performs excessive healthrelated behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor) Case study: Melinda • 68-year-old woman with rheumatoid arthritis • Has always described herself has an anxious person • Experiences significant wrist and ankle pain throughout the day • She spends most of her day ruminating about the activities she can’t do anymore because of her symptoms • She also worries extensively about whether these symptoms will worsen • She often refuses to do her stretching exercises because she worries they will make her symptoms worst What other disorder is characterized by misinterpreting body sensations? Panic disorder versus somatic symptom disorders People with panic disorder typically fear immediate symptom-related catastrophes that may occur during the few minutes they are having a panic attack, and these concerns lessen between attacks. Individuals with somatic symptom disorders focus on a long-term process of illness and disease (e.g., cancer or AIDS). Psychological factors influencing medical conditions A. A medical symptom or condition (other than a mental disorder) is present. B. Psychological or behavioral factors adversely affect the medical condition in one of the following ways: 1. The factors have influenced the course of the medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition. 2. The factors interfere with the treatment of the medical condition (e.g., poor adherence). 3. The factors constitute additional well-established health risks for the individual. 4. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention. Treatment for somatic symptom disorders • Requires collaboration with medical services • A “gatekeeper” physician may be required for people who access services excessively • Tests may be required to rule out actual medical problems • Management of underlying disorder (for somatic symptom disorder) • Illness anxiety disorder • Exposure-based methods and CBT “Unexplainable” medical symptoms Conversion Disorder Malingering Malingering Factitious Disorder Conversion disorder A. B. One or more symptoms of altered voluntary motor or sensory function. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. C. The symptom or deficit is not better explained by another medical or mental disorder. D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation • Examples of symptoms: weakness, paralysis, seizures, sensory symptoms (e.g. blindness, deafness) Malingering: faking symptoms for personal gain (not a mental disorder) DSM-5 Criteria: Factitious Disorder A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. B. The individual presents himself or herself to others as ill, impaired, or injured. C. The deceptive behavior is evident even in the absence of obvious external rewards. D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder. • Specifers • Imposed on self • Imposted on others Dee Dee Blanchard: https://www.youtube.com/watch?v=8i4JoQfvveA The Act (TV show trailer): https://www.youtube.com/watch?v=S1QmDDEific Unexplainable medical symptoms (presumed to be psychological-based) Conversion Disorder Malingering Malingering Factitious Disorder Faking symptoms Conversion Disorder Malingering Malingering Factitious Disorder Faking symptoms for personal gain Conversion Disorder Malingering Malingering Factitious Disorder Faking symptoms for no obvious reason Conversion Disorder Malingering Malingering Factitious Disorder The validity of Conversion and Factitious Disorders are highly controversial because of several limitations 1. Limitations of modern medicine • How can we be certain that a symptom is not medically explainable? 2. Limitations on self-report information • How can we conclusively determine whether symptoms are genuine or not? • How do we do conclusively determine that there is nothing to be gained? • How can we reliably distinguish between conversion disorder, malingering, and factitious disorder? 3. Limitations on assessment/treatment research • There are not many clear, evidenced-based ways of treating Conversion and Factitious Disorder • Limited epidemiological evidence (prevalence, prognosis) Summary Obsessive-Compulsive and Related Disorders • OCD • Body Dysmorphic Disorder • Hoarding Disorder Somatic Symptom and Related Disorder • Somatic symptom disorder • Illness anxiety disorder • Psychological factors affecting medical condition • Conversion disorder • Malingering • Factitious Disorder