2S4L: OCD and Traumatic Disorders PDF

Asst. Prof. Joselito Diaz, MD, MHA, FPNA, FPCPsych Alvior, Aquino, Bolanos, Centeno, Dequito, Gonzaga, Panteras, Pascual, Que, Ramos, R., Reyes, M.,Rodil, Tizon, Valencia 2S4L: OCD AND TRAUMATIC DISORDERS...

Asst. Prof. Joselito Diaz, MD, MHA, FPNA, FPCPsych Alvior, Aquino, Bolanos, Centeno, Dequito, Gonzaga, Panteras, Pascual, Que, Ramos, R., Reyes, M.,Rodil, Tizon, Valencia 2S4L: OCD AND TRAUMATIC DISORDERS Disorder 9 OUTLINE D. Dsm-5 Diagnostic Criteria For Disinhibited Social I. Obsessive-Compulsive And Related Disorders 1 Engagement Disorder 10 A. Obsessive-Compulsive 1 B. Disorder 1 a. Obsession 1 OBSESSIVE-COMPULSIVE AND RELATED b. Compulsion 1 DISORDERS C. Video Sample: Ocd 1 a. Commentary 2 OBSESSIVE-COMPULSIVE D. Dsm-5 Diagnostic Criteria For 3 DISORDER Represented by a diverse group of symptoms that include E. Obsessive-Compulsive Disorder 3 intrusive thoughts, rituals, preoccupations, and F. Ocd: Symptom Patterns 3 compulsions a. Contamination 3 Causes severe distress to the person b. Pathologic Doubt 3 ○ Time-consuming, interfere with daily functioning, c. Intrusive Thoughts 3 effect on relationships d. Symmetry 4 A patient with OCD may have an obsession, a e. Other Symptom Patterns 4 compulsion, or both G. Video Sample: Hoarding Compulsion 4 Lifetime prevalence: 2-3% 4th most common mental disorder after phobias, H. Video Sample: Hoarding Compulsion 4 substance-related disorder and MDD a. Commentary 4 Adults: M=F; in adolescence: M>F II. Body Dysmorphic Disorder 4 Mean age of onset: 20 years Etiology A. Dsm-5 Diagnostic Criteria For Body Dysmorphic ○ Obsession: secondary to conditioning Disorder 4 ○ Compulsion: learned ways to avoid anxiety B. Video Sample 5 become fixed and ritualistic III. Hoarding Disorder 5 Onset is sudden and usually precipitated by a stressful A. Dsm-5 Diagnostic Criteria For Hoarding Disorder 5 event Video Sample 5 Course is chronic and variable ○ 20-30% significant improvement IV. Trichotillomania (Hair-Pulling Disorder) 5 ○ 40-50% moderate improvement A. Dsm-5 Diagnostic Criteria For Trichotillomania ○ 20-40% remain ill or worsen (Hair-Pulling Disorder) 5 1/3 have Comorbid MDD (Major Depressive Disorder) V. Excoriation (Skin-Picking) Disorder 6 and suicide rate is high Treatment A. Dsm-5 Diagnostic Criteria For Excoriation ○ Pharmacotherapy: SSRIs, clomipramine (Skin-Picking) Disorder 6 They would need a higher dose of the VI. Case Analysis 6 medication compared to depression, for VII. Trauma And Stressor Related Disorders 6 example: depression = antidepressant A. Biopsychosocial Model Of Health 6 the usual dose is around 10-20mg, but B. Posttraumatic Stress Disorder 6 for OCD, from 20mg up to 80mg in order C. Dsm-5 Diagnostic Criteria For Posttraumatic Stress to control their obsession, and Disorder 6 compulsion. D. Video Sample: Veterans On Symptoms Of Ptsd 7 ○ Behavior and Cognitive therapy VIII. Posttraumatic Stress Disorder 8 OBSESSION A. Dsm-5 Diagnostic Criteria For Acute Stress Disorder 8 a recurrent and intrusive thought, feeling, idea, or a. Intrusion Symptoms 8 sensation (mental event / thought disturbance) b. Negative Mood 8 ○ Can be diagnosed already with OCD c. Dissociative Symptoms 9 d. Avoidance Symptoms 9 COMPULSION e. Arousal Symptoms 9 a conscious, standardized, recurrent behavior (behavior) B. Dsm-5 Diagnostic Criteria For Adjustment Disorder 9 ○ Can be diagnosed already with OCD a. Specify Whether: 9 ○ Motor act that is carried out in an attempt to b. Treatment 9 reduce anxiety associated with an obsession ○ Anxiety increase if a person resists carrying out a C. Dsm-5 Diagnostic Criteria For Reactive Attachment compulsion 1  OCD AND TRAUMATIC DISORDERS VIDEO SAMPLE: OCD ○ Efren’s brother would play around with him (washing) Efren would turn the light of with his elbow by grabbing him and putting their feet to his as he claims his hands are clean and the switches are face to prove to him that nothing bad will dirty happen. ○ He then proceeds to the bathroom and wash At night, Efren would repeatedly check the latch on his hands there while counting to set a the door and the knob to make sure that it is locked. certain duration of time. He washes the Efren’s family can provide for their needs. His brother faucet as well since he touched it. was a bar top notcher and his other brother has an ○ Whenever he uses the toilet, he would push executive position in the big company that he works the flush using his foot. for. Their parents raised them to be organized with Efren claimed that he has Obsessive-Compulsive their things. Disorder They joke around that “May pagka-OC din sila” ○ “Isang chemical imbalance sa utak ng tao na “For example, when I was in law school, pinagmumulan ng mga bagay na lahat ng books ko sa shelf ko color coded. pabalik-balik sa kanyang isipan kahit hindi so all maroon, green, blue ones are all niya ito kagustuhan.” Efren demonstrates together” “all my ballpens should be aligned grabbing a spoon with the fork. “Dahil dito, and in the order of how many times I use it.” nagkakaroon siya ng compulsions, o mga - Atty. Reinie Yebra (brother of efren) bagay na paulit-ulit niyang ginagawa para However, the condition of their youngest is not a maibsan ang kanyang pag-aalala.” joking matter. Efren is an Electronics Engineer from a middle class ○ “The very first thing that should be family, and he was never ashamed of his OCD. recognized is that may problem talaga. A ○ Efren: “Ever since po nung bata ako, mga constant reminder that you have to Grade 2, nagumpisa na yung sa (pag)hugas emphasize that hindi lang sya yung affected, ng kamay. Tapos ang naalala ko lang po but also the family. The important thing for yung nagbasa ako about cholera, na parang our part, is that we should have patience.” ang cholera pala nakakamatay ‘yon, at Efren has a girlfriend (Michelle, a SLP) of 6 years nakukuha ‘yon kapag madumi yung kamay ○ They go to a day care center for a birthday mo na sinubo mo sa bunganga mo.” party, which has a lot of people, and a Upon observing Efren, I noticed his “ritual” unstructured environment, which is not ○ He would put his hand under the faucet, turn suitable for someone with OCD it on, and off again, and put his hand under ○ “Sa shorts ko, natatakot ako na baka the tap to see if there really is no water magkaroon ng AIDS, tas pag sa dikit-dikit sa coming out. This routine confirms to his brain mga tao, natatakot ako na mahawaan ako that the faucet is off. ng mga bacteria nila, mag ka-body odor ako. The day isn’t even finished yet, and he already Kaya kapag may sugat ako ntatakot ako washed his hands four times. After which he will hawakan or madumihan sya o magkaroon eventually take a shower. ako ng AIDS” ○ Efren stated that he used to take 3 hours ○ “Kaya takot ako lumabas kase baka showering, but now it’s 30 minutes. His magkaroon ng cancer lungs ko” brother taught him that “Okay na yan, 2-3 ○ “Ano nasa isip mo na paulit ulit ka?” “naka times mo lang sabunin yung katawan mo.” focus utak ko, kailangan naka focus sya and ○ After showering he irons his underwear. dapat malinis na sya para saken.” ○ When donning shorts, he must not touch the ○ “Hindi mo ba napipigilan?” “Maiiwasan mo insides with the sole of his foot. “Baka sya parang hindi mo sya iisipin, pero hindi magk-AIDS ako, mapunta duon sa shorts mo sya mapipigilan until satisfied ka and yung virus kaya kailangan perfect ko siyang nagawa mo na yung mga routine mo. masuot nang ‘di nattouch. Binaliktad ko para Even though Efren wants to submerge himself in yung labas yung matouch pag nagkamali those moments, he can't. ako. Kunwari natouch ko na siya, ‘di ko na ○ He can't even sit because of his yan gagamitin tatapon ko na siya.” cautiousness that the chair is dirty. ○ He hangs his towels for different parts of his ○ His girlfriend had to sit down first in order for body in different places. Efren to see that it’s okay to sit down on it. After four hours, Efren’s morning ritual is done. ○ Ang pag hahalibilo with others present a big DOC DIAZ: In this video, you can see the different challenge already for Efren, but we withstood OCD patterns. There is the contamination, as he it for his girlfirend. believes he may get HIV or AIDs if his foot touches How is the relationship between you and your the inside of his shorts. Same thing with his girlfriend? underwear where he has to iron it before wearing it ○ “Pag naghholding hands po kami, inaalcohol just to kill the germs. There’s also the symmetry ko po muna kamay nya” regarding his linens, and all his towels have a ○ “He hates kapag hinahawakan ko sya bigla, particular place in the room. Also with the sink, where dapat mag alcohol muna ako or mag wash he has to put his hand beneath the faucet to make with soap. Kahit hindi lang sa hands ah, any sure that there is no water that is dripping. part of the body I habe to use alcohol muna Efren rubs alcohol on his hands upon shaking the or wash my hands. He has to see it clean” reporter’s hand. COMMENTARY Sometimes, we joke around about being “OC”, but for So that particular video showed the different compulsions Efren it is his reality that is hard to escape from. that Efren has to do and how it has impacted his social life Fortunately, his family supports him. and how distressing it is for him and how time consuming 2  OCD AND TRAUMATIC DISORDERS it is. If you can hear what he says regarding handwashing, prevent them from having bathing, he would always mention “ang sabi ng kuya ko” accidents. that would bring about what would be the treatment, like how it is a behavior and cognitive na therapy, as he B. The obsessions or compulsions are time-consuming mentioned “If i wash 3 times, malinis na ang katawan ko” (e.g., take more than 1 hour per day) or cause or “If i wash my hands 3 times, it is already clean sabi ng clinically significant distress or impairment in social, kuya ko”. So that would tell you the one form of treatment. occupational, or other important areas of functioning. Another form of therapy is the behavioral therapy which is C. The obsessive-compulsive symptoms are not done by the father and brothers, where they would hold attributable to the physiological effects of a substance him and put their feet into his face, so that he may realize (e.g., a drug of abuse, a medication) or another that he was not going to die of any illness if he is medical condition. “contaminated”. Individuals with Tourette’s usually have a Onset may be very sudden and usually precipitated by a concurrent obsessive-compulsive disorder stressful event as mentioned above, but in the case of secondary to a medical condition Efren, he mentioned about reading cholera and how D. The disturbance is not better explained by the cholera can be contracted by contaminated food, so that is symptoms of another mental disorder (e.g., excessive one that triggered the obsession. worries, as in generalized anxiety disorder; preoccupation with appearance, as in body DSM-5 DIAGNOSTIC CRITERIA FOR dysmorphic disorder; difficulty discarding or parting OBSESSIVE-COMPULSIVE DISORDER with possessions, as in hoarding disorder; hair pulling, A. Presence of obsessions, compulsions, or both: as in trichotillomania [hair pulling disorder]; skin Obsessions are defined by (1) and (2): picking, as in excoriation [skin-picking] disorder; 1. Recurrent and persistent thoughts, stereotypies, as in stereotypic movement disorder; urges, or images that are ritualized eating behavior, as in eating disorders; experienced, at some time during preoccupation with substances or gambling, as in the disturbance, as intrusive and substance-related and addictive disorders; unwanted, and that in most preoccupation with having an illness, as in illness individuals cause marked anxiety or anxiety disorder; sexual urges or fantasies, as in distress. paraphilic disorders; impulses, as in disruptive, 2. The individual attempts to ignore or impulse-control, and conduct disorders; guilty suppress such thoughts, urges, or ruminations, as in major depressive disorder; thought images, or to neutralize them with insertion or delusional preoccupations, as in some other thought or action (i.e., schizophrenia spectrum and other psychotic by performing a compulsion). disorders; or repetitive patterns of behavior, as in Compulsions are defined by (1) and (2): autism spectrum disorder). 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or OCD: SYMPTOM PATTERNS mental acts (e.g., praying, counting, repeating words silently) that the CONTAMINATION individual feels driven to perform in response to an obsession or Obsession of contamination followed by washing or according to rules that must be compulsive avoidance of the presumably applied rigidly. contaminated object 2. The behaviors or mental acts are Contaminants: feces, urine, germs, dust aimed at preventing or reducing Contamination is spread from object to object or anxiety or distress, or preventing person to person some dreaded event or situation; ○ In order for them to not be contaminated by however, these behaviors or mental germs or microbes acts are not connected in a realistic Excessive hand washing, unable to leave home way with what they are designed to because of fear of germs neutralize or prevent, or are clearly Patients experience anxiety of the feared object as excessive. well as shame and disgust ○ They have to perform this or they feel Young children may not be able to articulate the aims of anxious these behaviors or mental acts. PATHOLOGIC DOUBT Compulsions are mental behaviors that the Obsession of doubt followed by compulsion of individual fell driven to in order to prevent the checking anxiety brought about by the obsession or to Forgetting to turn off the stove or not locking the door prevent some dreaded event or situation ○ Most common would be locking door, they ○ Compulsions not considered for have doubts if they’ve locked it Catholics if they are passing by the ○ Usually at night they have to lock all the Church doing sign of the cross doors and windows or they won’t be able to since if they don’t do that, it results sleep to bad fortune Multiple trips back into the house to check ○ Filipinos usually have icons such as Sto. Nino, cross, or Mama Mary. Before they start their work, they INTRUSIVE THOUGHTS touch these icons and pray to Intrusive obsessional thoughts without compulsion 3  OCD AND TRAUMATIC DISORDERS Thoughts of aggressive or sexual act that causes - “It belonged to our brother, Donny, who got killed in shame and guilt Vietnam. He was 16 days short of being 20 when he ○ They would be able to kill someone or do was killed. He was the best big brother you could sexual acts have” May report themselves to police or confess to a priest - “He was good looking, nice, friendly, everybody liked ○ Even if they have not acted on them, since him. Donny was always there for us. I cant. “ the thoughts are repetitive - “I would say after he died, that, definitely things went ○ Doc had a patient who was a college student downhill for them. It was just something that the family before that had intrusive thoughts on a couldnt accept. They could not accept it at all. I that classmate that he doesn’t personally know. remember my aunt, she just, she just couldnt bear the He met him during work wherein she visited thought of losing him totally. So i dont think the girls the store and had sexual thoughts on her. ever ever got over Donny” ○ In order to remove the possibility of him - “I really dont know much but that this were his. I dont being a homosexual, he would have sexual know anything about it, theyre all the same.” thoughts on former partners, and even sex - Yeah, it was a way to escape. A way to forget. workers, and will be engaging in discreet - Over the next 40 years, the twins’ hoarding sexual encounters. compulsion gradually increased, slowly, their massive Same px, shared that he was hoarding began to wreak havoc. sexually abused by a neighbor - “Hoarding i guess, just took over my life.” - First they were both fried from their jobs at the local SYMMETRY bakery which they held for 34 years, shortly after, their hoarding cost them their first home as well. Need for symmetry and precision that leads to - “They were basically evicted and the town tore down compulsion of slowness their home. It was just sad. Everyone was so ○ If things are not in their proper place or determined to get them out and tear it down.” properly aligned, they are not able to go - “Yeah,weve had a lot of problems. Weve lost the old back to their daily activities. home place. Things just got out of hand and we were Take hours to eat or shave their faces cleaning it for them. Even though we tried” - Now the sisters are facing the same with their current OTHER SYMPTOM PATTERNS home, just after 5 years of renovation, after the city Religious obsessions inspection they were given 30 days to clean up or Compulsive hoarding face eviction. Masturbation - “Once they saw the house they said, youve got to get ○ Compulsion to do the act this cleaned up and if not, then if it is not cleaned out Trichotillomania and nail biting youd be out” ○ Trichotillomania is considered a different - “I have this fear that they would condem the house we disorder. will have no place to live” - “This is their one chance, to lose this home they will VIDEO SAMPLE: HOARDING COMPULSION become homeless. Thats my worst fear” The video is about an individual who has OCD, he may appear normal and he is highly educated. However you COMMENTARY can observe the different OCD patterns, the most apparent would be that of pathological doubt when it comes to This particular sisters has already lot their previous home contamination and obsession regarding symmetry that has because of the hoarding and yet they continue with the started to affect his activities. hoarding. We can see how cluttered the place is and how ○ First scenes are of the individual washing his it is already impacting their social and cocupational hands and cleaning. functioning. Theyre already getting sick because of all the “Kailangan kasi pag nag-aayos ako ng kumot kailangan cluetter, the possible contaminants because they have pantay siya. Yung eksaktong pantay talaga.” cats, fecal materials, even rodents, mice can live in that Efren describes what a dirty soap is, it’s the one that you cluttered place. But still, they contnue to keep their use when you get home from outside. “Sinasakto ko lang possessions and as to traumatic event that triggered all of ng 3 times kada finger, kada parte. Dati infinite yan this, as mentioned it is the loss of the brother when they hangga’t di ako masatisfy, sabi ng kapatid ko okay na yan. were younger. Another factor would be unacceptance of Kaya finofollow ko yung numbers.” the death of the brother by the mother. It also plays an “Pagkatapos kong hugasan yung kamay ko dito, ang important role in the development of this particular gagawin ko ay huhugasan ko naman ‘to (faucet). Kasi hoarding disorder. nahawakan mo na nung ‘di ka pa naghuhugas. Pagkatapos niyan okay ka na.” BODY DYSMORPHIC DISORDER VIDEO SAMPLE: HOARDING COMPULSION DSM-5 DIAGNOSTIC CRITERIA FOR BODY “When I was younger, things were fine. But after my DYSMORPHIC DISORDER brother was killed, everything just fell apart,” A. Preoccupation with one or more perceived defects or - At just 10 years old the twins’ entire world fell apart flaws in physical appearance that are not observable when their older brother, Donny, lost his life in the or appear slight to others. Vietnam war. From that momet, their lives spiraled B. At some point during the course of the disorder, the into a seemingly bottomless state of despair individual has performed repetitive behaviors (e.g., - “This is my brother Donny’s uniforms and theyre mirror checking, excessive grooming, skin picking, basically priceless” reassurance seeking) or mental acts (e.g., comparing 4  OCD AND TRAUMATIC DISORDERS his or her appearance with that of others) in response Case: Elias, 17 y/o to the appearance concerns. ○ BDD got so bad that he was treated as an They feel that there is flaw in their body inpatient in a hospital for 2 months C. The preoccupation causes clinically significant ○ “I got to the point that makeup is not enough. distress or impairment in social, occupational, or other People could still see my face. I hate the way my important areas of functioning. face looks. I just come there and people start D. The appearance preoccupation is not better explained looking at me.” He then started wearing a mask by concerns with body fat or weight in an individual and a hat. whose symptoms meet diagnostic criteria for an ○ Was pretty much confined in their house eating disorder. ○ His mom had to stay at home and stop working as she did not trust him to stay on his own Some individuals, they would appear normal but they ○ “If she was in my room, I wouldn’t go into it.” would be claiming that there is particular defect (e.g., ○ “I got so bad that I felt – okay, it’s not just another their eyes are not symmetrical which is normal, their people, it’s my parents as well. They can’t see nose is pug even though matangos naman; maliit me because I’m too ugly for my parents to see yung breast even if it is not) me.” In time, people get to manage their symptoms. VIDEO SAMPLE.We live in a world obsessed with body-image and the way HOARDING DISORDER that we look but what happens when the way you think you look takes over your way of life? DSM-5 DIAGNOSTIC CRITERIA FOR HOARDING “I used to sit in the lounge and with the curtains drawn DISORDER because I was paranoid someone’s looking” A. Persistent difficulty discarding or parting with Children and teenagers are battling around the country possessions, regardless of their actual value. (US) are battling body dysmorphic disorder B. This difficulty is due to a perceived need to save the BDD is an obsession with flaws and a person's items and to distress associated with discarding them. appearance that others barely notice. C. The difficulty discarding possessions results in the Many cases they’ve done self-surgery accumulation of possessions that congest and clutter Case: Emily, 18 y/o, obsessed with make-up. active living areas and substantially compromises ○ “I feel like it’s covering my flaws, like a their intended use. If living areas are uncluttered, it is camouflage. For me, it’s just my face in general. I only because of the interventions of third parties (e.g., just hate the way I look.” family members, cleaners, authorities). ○ Her BDD got so bad that it affected her studies D. The hoarding causes clinically significant distress or ○ Tried hanging herself as she felt disgusted with impairment in social, occupational, or other important herself. areas of functioning (including maintaining a safe ○ “I just didn’t feel pretty enough to be even in front environment for self and others). of my family.” E. The hoarding is not attributable to another medical ○ She is not getting help and therapy and condition (e.g., brain injury, cerebrovascular disease, medications seems to be helping Prader-Willi syndrome). ○ Father: For 4 years, she has been a One thing that we need to rule out is school-refuser, we couldn't plan/go on holidays dementia, individuals who hoard may be because it would get to the point when we’re suffering from dementia. about to leave the house, she won’t be able to go F. The hoarding is not better explained by the symptoms ○ Went to a clinic and therapist wanted to see her of another mental disorder (e.g., obsessions in how far she have come obsessive-compulsive disorder, decreased energy in The challenge for her during their major depressive disorder, delusions in schizophrenia session is to remove her makeup and or another psychotic disorder, cognitive deficits in go outside. When she got outside, she major neurocognitive disorder, restricted interests in felt anxious and decided to go back autism spectrum disorder). inside before panicking because it was too busy. VIDEO SAMPLE “I felt really insecure and a bit hopeless “This is the living room/bedroom” (shows a room filled with in a way.” trash” Case: Megan In Percy, Illinois, Phyllis and Patty aren't just identical ○ Was a straight A students but left school with twins, they're identical twin hoarders. Every house they've very few qualifications ○ “My mom would drive me and I would sit outside ever resided in has been completely demolished by them. school and just cry. I worried that they were all The problem they are currently facing is whether or not looking at me and thinking and looking at they can save their present home from being condemned. everything wrong with me.” This was not always the case, they had a normal ○ Leaving the house became a difficult task for her childhood but after their brother’s passing, “everything just and the build up can take for hours especially if felt apart” a twin uttered. They lost their brother when they it’s busy outside. were just 10 years old from the Vietnam war. He was just ○ She said that social media does not help with 60 days short from being 20y.o. their illness (there are those seeking reassurance Link to the video: about their appearance online, there are ○ https://www.youtube.com/watch?v=GP9tEliyBP8 hundreds and thousands of harmful body image posts on IG; and on FB, there are certain groups discussing about taking laxatives and 200cal/a day diets) 5  OCD AND TRAUMATIC DISORDERS TRICHOTILLOMANIA (HAIR-PULLING DISORDER) TRAUMA AND STRESSOR RELATED DISORDERS Disorders in which exposure to a traumatic or stressful DSM-5 DIAGNOSTIC CRITERIA FOR event is a diagnostic criterion TRICHOTILLOMANIA (HAIR-PULLING DISORDER) ○ There should be exposure to a traumatic or A. Recurrent pulling out of one’s hair, resulting in hair stressful event loss. Psychological distress following traumatic or stressful B. Repeated attempts to decrease or stop hair pulling. event is variable C. The hair pulling causes clinically significant distress or ○ Anxiety related disorder impairment in social, occupational, or other important ○ Phenotype that exhibit anhedonic and areas of functioning dysphoric symptoms, externalizing angry D. The hair pulling or hair loss is not attributable to and aggressive symptoms or dissociative another medical condition (e.g. a dermatological symptoms condition). E. The hair pulling is not better explained by the BIOPSYCHOSOCIAL MODEL OF HEALTH symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance There could be biological or genetic predisposition in body dysmorphic disorder) Early-Life social environment Looking at the possible psychological defenses as In individuals, you would see hair pulling disorder where this particular individual would possess they would have alopecia and the reason would be that If there is a traumatic or stressful situation, some particular compulsion to pull their hair. Another, is usually if individuals may be able to cope and may have no they are under stress, they would be pulling their hair psychiatric condition, but some may either develop depression, anxiety, psychotic disorder, some may EXCORIATION (SKIN-PICKING) DISORDER have a phenotype wherein they may exhibit anhedonic and dysphoric symptoms, externalizing DSM-5 DIAGNOSTIC CRITERIA FOR EXCORIATION angry and aggressive symptoms or dissociative (SKIN-PICKING) DISORDER symptoms A. Recurrent skin picking resulting in skin lesions. ○ These are individuals who will develop B. Repeated attempts to decrease or stop skin picking trauma or stressor-related disorders C. The skin picking causes significant distress or ○ Best example would be post-traumatic stress impairment in social, occupational, or other important disorder areas of functioning D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies) E. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury) People that are constantly scratching and they end up having wounds all over their body. Or they would be picking their skin thinking that there is scab that they need to remove. Have to rule out that it is not somatic or body dysmorphic disorder. An example of an individual who has OCD. POSTTRAUMATIC STRESS DISORDER CASE ANALYSIS Principal features: painful reexperiencing of the event, a pattern of avoidance and emotional numbness and Susan, who is seventy, agrees that she is a very "clean" fairly constant hyperarousal person. She spends much of each day cleaning and ordering ○ You have to fulfill all of these to diagnose an her house. She describes having this behavior ever since individual with PTSD childhood, when she avoided getting muddy and dirty. She May even develop months or years after the stressful says that her husband doesn't mind: "He says I'm a good event housekeeper." Susan seems happy, too; proud of her clean ○ Those involved in war, during the battle, they house. However, more probing with questions reveals the don't have any psychiatric problem but once extent of her problem: she explains that, all her life, she has they are discharged from service, they are felt very anxious about dirt, germs, and disorder. Earlier in her living a normal civilian life, they will life she spent essentially all of each day cleaning, sometimes experience symptoms of PTSD confining herself to one small square of a room, "so I could Associated symptoms: aggression, violence, poor really get it clean." This behavior led to the loss of her only job impulse control, depression, and substance-related (ironically, as a cleaning woman) and, for a time, estrangement disorders from her husband and children. Her anxiety disorder was Symptoms must last for more than a month complicated by depression in her thirties and forties. Acute stress disorder: