Lecture 6 - PTSD and OCD Flashcards
Where are PTSD and OCD in the HiTOP model?
Internalizing
-Fear… OCD
-Distress… PTSD
OCD (Obsessive-Compulsive Disorder) History
- 1691 sermon on religious melancholy
- Parishioners obsessed by “naughty, and
sometimes Blasphemous Thoughts [which]
start in their Minds, while they are exercised in
the Worship of God [despite] all their
endeavours to stifle and suppress them … the
more they struggle with them, the more they
increase.” - John Moore, Bishop of Norwich, England
- OCD has traditionally been a DSM anxiety
disorder - ICD-10 (1992) created the category of “neurotic,
stress-related, and somatoform disorders” - OCD was its own subcategory
- DSM-5: No longer an anxiety disorder
- However, the sequential order of the anxiety
disorders and the obsessive-compulsive disorders
chapters in DSM-5 “reflects the close relationships
among them.” (APA, 2013)
OCD Characteristics
- A. Presence of obsessions, compulsions, or both (more on this to follow)
- B. Obsessions or compulsions are time-consuming (e.g., more than 1 hour per day) or cause
clinically significant distress or impairment in social, occupational, or other important areas of
functioning. - C. Symptoms are not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition. - D. The disturbance is not better explained by the symptoms of another mental disorder
- Specify if: With good or fair insight, With poor insight, With absent insight/delusional beliefs:
- Specify if: Tic-related: The individual has a current or past history of a tic disorder.
Obsessions
* Persistent ideas, thoughts, impulses,
and images that are experienced as
being intrusive and inappropriate, and
cause marked anxiety or distress
* Ego dystonic (b/c intrusive and
inappropriate)
* A sense of lack of control
* Not a “natural” part of the person’s personality
* BUT the person recognizes that these are his/her thoughts
* Distinguished from schizophrenia or psychosis
* No delusional system of thought insertion
* NOT just worries about real-life problems
*Examples:
- Contamination (most common)… ex: if a fly had touched a piece of toast but left, most people with still eat the toast. Some people with ocd might consider it contaminated and not eat it (if you eat it you will get sick and die) Also related to germs and stuff)
- Uncertainty (did I leave the stove on? what if this person isn’t alive rn?? Have to check)
- Aggressive (thoughts of hurting others or self)
- Symmetry/ Exactness (can’t be satisfied just by putting things in order… can come with magical thinking (if not organized by height, my mom will die)… not just ‘I like it tidy’)
- Sexual
- Somatic (Fear one must have aids, cancer…. Many many times throughout the day… do compulsion… call doctor again… a lot)
* People with OCD almost never act on their impulses
* Most OCD patients have multiple obsessions
* Some developmental differences
- Children less likely to have sexual obsessions
- More likely to have aggressive obsessions
Compulsions
* Repetitive Behaviors (sometimes thoughts… mental behaviors)
* Attempts to neutralize or suppress obsessions
* Designed to reduce anxiety from the obsession
* Not designed to bring pleasure or gratification
- For example, some people engage in compulsive sexual
behavior, or eating, or gambling, etc.
- Not OCD compulsions
- All designed for gratification
* Person MUST perform the behavior
* Sometimes simple actions, sometimes
very bizarre and complex
* Frequently a form of “undoing” the
thought or fear
*Common compulsions
- Washing/Cleaning compulsions (ex: have to wash hands 10 times to undo thought)
- Checking (ex: reassurance, verifying didn’t leave the stove on, there’s no child behind the car… again and again)
- Repeating (ex: turning on and off…. Until feels right)
- Mental (rituals in head to undo bad thought… ex: thinking a good thought after a bad one, saying prayer in mind)
Diagnosis
* Most people will have both obsessions and compulsions
* Don’t need both for the diagnosis
* ¼ will have ONLY obsessions
- But often these people will ritualize mentally
* Very rare to have compulsions without obsessions
- If seen, usually in children– counting, touching, ordering (they don’t yet know why they’re doing it or struggle to express why)
Epidemiology and course of OCD
- Lifetime prevalence about 1.5%
- Prevalence the same in adults and children
- OCD slightly more common in females than males
- In children more common in males
- Age of onset– about 19
- Usually gradual onset
- 40-year follow-up study of “natural” course (Skoog & Skoog, 1999); First hospitalization
OCD patients - At end of 40 years, 20% had completely recovered
- 28% had recovery with subclinical symptoms
- 52% still experiencing clinically significant symptoms
- Of those who recovered, usually in the 1st 5 years of first hospitalization
OCD and Disgust
- Disgust Proneness (tendency experience disgust very frequently and intensely)
- Genetic and learning influences
- Disgust proneness may also play a role in other
disorders - Spider Phobics and cookie (if spider touches your cookie but then leaves, would you still eat the cookie after?)
- OCD may reflect a false contamination alarm
- Very hard to counter-condition
- Can explain some of the challenges in treatment
Cognitive Models of OCD
- Obsessive thoughts very common in non-OCD people too
- OCD = experience them as intrusive or
upsetting - Inflated sense of personal responsibility
and self-blame - If the thoughts come to pass (to happen), it’s their
fault - This makes them upset
- NA increases the rate of thoughts
- Get more upset, etc.
- Must ritualize to reduce anxiety
Theory of ocd and memory
* OCD due to deficits in short-term
memory
* People can’t remember if they’ve
checked
* Also very difficult to distinguish between
real and imagined events (reality testing)
- Can’t remember if they checked, or if
they thought about checking
* Often convinced thoughts are true
Intolerance of Uncertainty
* Jonathan Grayson
* “The tendency to react negatively on an emotional,
cognitive and behavioral level to uncertain situations and
events’’ (Dugas, Buhr, & Ladouceur, 2004)
* Individuals who are intolerant of uncertainty believe they
lack sufficient coping or problem-solving skills to
effectively manage threatening situations
* Compulsions often attempts to increase certainty
Ex: Obsession: Is this person alive rn? How can you be sure? Compulsion: Checking, some other ritual…
Thought/Action Fusion (TAF)
*Like jinxing… believe own thoughts affect the real world
* Shafran, et al., 1996
* AKA “magical thinking”
* Moral TAF: unwanted thoughts about disturbing actions equivalent to the actions
themselves (e.g. Rachman, 1998; Salkovskis, 1999) (having thoughts just as bad as doing the thing thought about)
* Likelihood TAF: thinking about a disturbing event makes the event more probable
(e.g. Rachman, 1998; Salkovskis, 1999)
Ex: would you write on a piece of paper “x person will die this week”? and carry it in your pocket all week? Most people wouldn’t, even though writing it on a piece of paper doesn’t make it more likely to happen. This is an example of magical thinking and likelihood TAF.
Neutralization
* Rachman, Shafran, Mitchell, Trant, & Teachman (1996)
* 63 undergraduates with some degree of self-reported TAF
* “Keeping in mind a friend or relative who is close to you, I would like you to write out the
following sentence on this piece of paper, inserting the name of the person in the blank.”
* “I hope _____ is in a car accident.”
* “Close your eyes and think about the situation for a few seconds.”
Results:
-Participants in Immediate neutralization… anxiety decreases from provocation to neutralizing
-Participants Not allowed to neutralize… anxiety also decreased on its own!…. but desire to neutralize and feelings of guilt still stayed high, despite anxiety going down!
Often engage in neutralizing (or worry in GAD) to give ourselves ILLUSION of control
PTSD (Post-Traumatic Stress Disorder) history
- First appeared in 1980, DSM III
- Roots go farther back
-Before, symptoms were noticed… often called combat fatigue, war neurosis… - DSM I and II stressors were seen as
triggers of pre-existing diathesis - Forms of dysfunction we now call PTSD
were classified in other categories
according to presenting
symptomatology.
-Trauma induced (depressive, anxiety…) disorder - Vietnam war
- High rates of disorder in soldiers
- Similar patterns in survivors of rape and natural
disasters - Departure from other DSM categories:
- trauma is the presumed common etiological factor
- disorder is organized around it
- other disorders are not organized around etiology.
- Highly controversial
PTSD Criterias
DSM-5 criteria
* Need exposure to a traumatic event (Direct exposure, witnessing, learning close other (violent or accidental), exposure to frequent traumatic events happening to others (ex: first responders))
* Re-experiencing of the event in some
way
* Avoidance (behavioural or cognitive)
* Negative alterations of cognitions
and mood
* Marked alterations in arousal and
reactivity associated with the
traumatic event
* Duration of the disturbance is more
than 1 month
Epidemiology of PTSD
- DSM-III: PTSD thought to be rare (3%)
- Now: 7%-8%
- 2F:1M
- Rates of traumas are higher:
- 60% men, 51% women report traumas
that meet 1st criterion. - Why so many trauma but fewer PTSD
cases? - Why similar rates of traumas in men
and women but twice as many women
have PTSD?
–Maybe types of trauma experienced different : women=rape molestation, men=violence - Overall, following trauma, 9% develop
PTSD. - Women twice as likely as men (13% vs
6%). - Highest risk associated with assault or
violence. - Kidnapped/tortured: 54% (Among those who experience these, 54% develop PTSD)
- Rape: 49% (Amongst those who experience rape, 49% develop ptsd)
- Still only about 50% of people
experiencing trauma exhibit PTSD (Huh? thought it was 9%? Ask)
Cross-cultural
* Cross cultural studies:
* Rates of PTSD much higher in
developing non-western countries.
* Many of these studies done following
periods of turmoil and war
- may be getting elevated rates.
* Symptoms vary in different cultures.
Predictors of PTSD following trauma (rewatch part of lecture)
- Gender: women are more likely to
experience PTSD - Familial psychopathology predicts PTSD—
not specific - Preexisting psychopathology, esp.
depression. - Internalizing symptoms in early childhood
- Childhood traumas/history of earlier
traumas. - People with lower IQ at greater risk for
PTSD - Nature of trauma:
- Proximity
- Duration
- Level of life risk
- Intention
- Psychological processes occurring
during and after trauma - Most variance: DISSOCIATION
- Social Support after trauma
Controversies in Defining and Classifying PTSD (rewatch part of lecture)
- Most common controversy= what constitutes a
trauma? - Is PTSD a normal response to an abnormal event?
- Or an abnormal response to a normal, if stressful
event? - In DSM III – event had to be outside the range of
usual human experience - therefore extreme response is understandable.
- But what events are outside the range of normal
human experience? - Rape/murder/torture can be common in some places,
not in others - Can PTSD result from events w/in normal range?
- Car accident?
- DSM IV got rid of “normal human
experience” concept, - “Conceptual bracket creep”
- Recent studies have looked at rates of PTSD
following traumas, compared to rates of
PTSD following stressful life events (not
necessarily traumatic). - Rates of PTSD symptoms were higher after
life stressors than for traumas. - Do you need a full-blown trauma for PTSD?
- Is diathesis more important than the
stressor? - Depression is as likely an outcome following
a trauma as PTSD - Close relationship between PTSD and depression
- Comorbid
- Predict one another
- Similar characteristics:
- Greater prevalence in females
- Over-generalized autobiographical memories
- Smaller hippocampal volume
- Increased amygdala reactivity
- Risk of developing depression is just as high after a trauma
as PTSD - Are they separate disorders, or do they have a
common diathesis?
Etiology of PTSD
- Vietnam twin registry:
- Controlling for combat exposure, 33% of
variance due to A. - Even w/out combat exposure, some vulnerability
to PTSD - Same registry: Identical twins, one served in
Vietnam the other didn’t - Twins who served in Vietnam much more likely
to have PTSD than those who did not. - Evidence for genetic factors as well as
etiological events
PTSD and biological abnormalities
- A number of biological abnormalities observed in PTSD
- Hippocampal abnormalities often reported in PTSD (in volume and or functioning .. encoding memories and stress regulation)
- Involved in explicit memory processes and encoding of context during fear
conditioning - Interacts critically with the amygdala during encoding of fear memories
- Reduced volumes
- Reduced neuronal integrity (neurons communicating less effectively)
- Reduced functional integrity (Decreased response in a task)
- Smaller hippocampal volumes associated with:
- verbal memory deficits, combat exposure severity,
- dissociative symptom severity, depression severity, PTSD symptom severity
Scar? (What causes what? Bio abnormalities make you vulnerable to trauma? Or bio abnormalities= scar of trauma?)
* Most of this research cross-sectional (i.e., correlational)
* Are brain abnormalities observed in PTSD caused by the generative trauma?
- If so, they represent a “scar” of the trauma; may still be useful in etiological explanations
* Ample evidence from animal research that severe stress can damage the hippocampus
- Neurotoxic effects of cortisol; can cause atrophy and cell death of hippocampal neurons
- Hippocampus dense with receptors
* BUT correlation does not equal causation!
* Not everyone who experiences even severe acute stressors go on to develop PTSD
- In fact, majority do not
* Also, evidence that hippocampal volume is heritable; smaller sizes can alter
neuroendocrine responses to stress
Alternate explanations
* Abnormality may be an antecedent risk factor for exposure (abnormality could predict situations find yourself in.. behave in ways that bring about) to a traumatic event that could then
cause PTSD.
- Should then be observed in people drawn to situations associated with higher probability of trauma.
* Abnormality may be an antecedent vulnerability factor for developing PTSD upon exposure to a
traumatic event.
- Should be observed prior to exposure to independent acute stressors
* Abnormality may be the consequence of exposure to the traumatic event alone
- Should be found in both PTSD and non-PTSD trauma survivors equally but not in unexposed persons.
* Abnormality may be a manifestation or product of the PTSD, that is, a PTSD sign.
- Should only be observed in individuals who develop PTSD, not other trauma-exposed
* Abnormality may be the product of a sequel or complication of PTSD
-only in individuals with ptsd and should exhibit a worsening course, should be associated with more severe course/symptoms
Prospective Design and Twin Studies
- Measure biological factor in individuals prior to traumatic event and then
again afterward
*Why difficult?
Ex: 40% won’t experience trauma, a certain percentage won’t develop PTSD, those who do develop PTSD will often drop study
Would need about a thousand people at baseline… really expensive and hard
If take from army, might go back to risk factor for exposure theory
Twins discordant for trauma and PTSD
* Identify surrogates for what the traumaexposed person would be like but for the
experience of the traumatic event.
* Non-trauma-exposed, identical twin
- shares all the genes of exposed twin and much of
the exposed twin’s early developmental
environment (e.g., same family, same community,
same school).
- “Unique environment” (i.e., trauma experience) is
non-shared
- Case-Control design
- 17 combat-exposed Vietnam veterans with PTSD (ExP+)
- 17 non-combat-exposed co-twins of ExP+ (UxP+)
- 23 combat-exposed Vietnam veterans with no PTSD (ExP-)
- 23 non-combat-exposed co-twins of ExP-(UxP-)
- All male; in their early 50s
- Examined hippocampal volumes in each of the four groups
ExP+ = exposed trauma and ptsd
UxP+ = unexposed trauma and co-twin has ptsd
ExP-= exposed trauma and no ptsd
UnxP-= unexposed trauma and co-twin no ptsd
Results:
-total brain volume is not different, total hippo volume not different, total amygdala volume not different
-Similar abnormalities between the twins where one got ptsd! And the one with ptsd’s volume decreased a bit
Conclusion from the study: Reduced hippocampal volume = vulnerability factor for ptsd
Not about degree of trauma
Conclusions
* Smaller hippocampal volumes in trauma-exposed
individuals diagnosed with severe, unremitting
PTSD (consistent with previous research)
* Non-combat-exposed co-twins show comparable
hippocampal volumes
* Suggest smaller hippocampi in PTSD represent a
pre-existing, familial vulnerability, not the result of
neurotoxic event(s)
* Combat-exposed vets showed higher rates of
major depression, and more severe alcohol
histories
* BUT combat unexposed twin brothers did not
Effect of reduced hippocampal volume
* Hippocampal morphology implicated in conditioning and extinction
of fear responses in animals, may be involved in the contextual
processing of fear
* Rodents with hippocampal lesions show stronger conditioned fear
* Smaller hippocampal volumes also associated with diminished
neuroendocrine regulation of the HPA axis
* Smaller inherited hippocampal volumes may therefore predispose
individuals to:
- acquire stronger and/or more persistent conditioned emotional responses
- OR stronger hormonal stress responses
- Or BOTH
- When exposed to a traumatic event
Final controversy of ptsd
- Methodological issue: research on PTSD is often done on people with a vested
financial interest in being diagnosed with PTSD!! - Some researchers have questioned how credible these rates are.
- Some studies have tried to verify trauma histories of people in these studies .
- 93% of Vietnam vets with PTSD had actually been in Vietnam
- 7% had never been in Vietnam or never been in the military
- Over ½ had no documented combat exposure.
- Were they malingering?
