Trauma and Stressor-related Disorders and Obsessive Compulsive Disorders (Week 5)

Question 1

PTSD Associated Features

Answer 1

> . Survivor guilt
. Self-destructive behaviour (not eating, sleeping, taking care of self), impulsive behaviour, somatic complaints, feelings of ineffectiveness, despair, helplessness, feeling of being permanently damaged, loss of beliefs, social withdrawal.
. Prolonger Grief Disorder may occur when traumatic event involves violent death of someone close to person

Question 2

PTSD in Children: Part 1

Answer 2

> . Can occur at any age
.DSM5TR specifies examples for children in relation to criteria and has separate diagnostic criteria for children under age 6
. Play re-enactment common; memories may not appear to be distressing
. Dreams may be frightening but without recognisable content

Question 3

PTSD in Children: Part 2

Answer 3

> . Higher frequency of negative emotional states/mood changes, constriction of play, less expression of positive emotions, irritable behaviour and angry outbursts or tantrums, reluctance to pursue developmental opportunities
. Developmental regression may occur

Question 4

PTSD Causes: Part 1

Answer 4

> . Trauma intensity/type/proximity, but also: biological, psychological and social factors
. Generalized biological vulnerability e.g. predisposition for anxiety, so response to trauma more likely to be PTSD
. Reciprocal gene-environment interactions (may inherit characteristics that make it more likely to be in risky situations where trauma may occur)

Question 5

PTSD Causes: Part 2

Answer 5

Generalized psychological vulnerability
>. Uncontrollability and unpredictability (NB: family instability may instill a sense that world is uncontrollable, potentially dangerous)
>. Unresolved emotions, helplessness
>. Social support, active problem solving

Question 6

Physiological responses to stress

Answer 6

> . When we encounter stress, oursympathetic(“fight, flight, or freeze”)system responds, our adrenal system is triggered, cortisol is released, and our body becomes prepared to move toward the threat (fight), move away from the threat (flight), or we may evendissociate(freeze).

> . Afterward, ourparasympathetic (“rest, digest, and heal”)system takes over, and our bodies are restored to “normal” functioning.

Question 7

Physiological responses in PTSD: Part 1

Answer 7

> . In PTSD, a person does not fully return to the parasympatheticsystemand is thus always primed for a fight-flight-freeze reaction. They are never fully at rest, alwaysvigilantand may have distortedperceptions of threat. An analogy might be to keep your foot on the gas pedal without letting up. Sooner or later the engine will begin to burn out.

Question 8

Physiological responses in PTSD: Part 2

Answer 8

It isnot uncommon for PTSD suffers to developaccompanying stress-based disorderssuch as fibromyalgia, chronic fatigue, clinical depression, or colitis. A sizeable portion also go on to develop anaddiction.

Question 9

Other Disorders: Part 1

Answer 9

> . 1.2 Acute Stress Disorder: more than 3 days but less than 1 month (not all go on to develop PTSD)

> . 1.4 Attachment disorder:
Disturbed and developmentally inappropriate behaviors in children, emerging before five years of age, in which the child is unable or unwilling to form normal attachment relationships with caregiving adults (related to inadequate or abusive parenting)

Question 10

1.3 Adjustment Disorder

Answer 10

> . Anxious or depressive reactions to identifiable life stressors that are generally milder than one would see in acute stress disorder or PTSD but are nevertheless impairing in terms of interfering with work or school performance, interpersonal relationships, or other areas of living. Symptoms do not persist for more than additional 6 months once stressor or consequences resolved
Do not meet criteria for mood or anxiety disorder
Distinguish from normative stress reactions: Here the magnitude of distress exceeds what could be expected or causes significant impairment

Question 11

Other Disorders: Part 2

Answer 11

a. Reactive Attachment Disorder:
Abnormally withdrawn and inhibited behaviour; child will very seldom seek out a caregiver for protection, support, and nurturance and will seldom respond to offers from caregivers to provide this kind of care

b. Disinhibited social engagement disorder:
A pattern of behavior in which the child shows no inhibition whatsoever in approaching adults

Question 12

Obsessive-compulsive and related disorders

Answer 12

Obsessive compulsive disorder
>. Body dysmorphic disorder
>. Hoarding disorder
>. Trichotillomania (hair-pulling)
>. Excoriation (skin-picking)
>. Substance/medication/medical condition-induced
Other specified e.g. nail-biting, lip-biting, cheek chewing

• characterised by preoccupations (or preceding emotional states) and repetitive behaviours/mental acts in response

Question 13

Obsessive-Compulsive Disorder

Answer 13

Presence of obsessions and/or compulsions
>. Obsessions:
Recurrent, anxiety-producing thoughts, impulses or images that are intrusive, unwanted, inappropriate to current context
Cause sufferer to attempt to ignore or suppress or neutralize (with some other thought or action)

> . Compulsions:
Ritualized behaviours or mental acts (thoughts) that person feels driven to perform in response to obsession (to provide relief)
Intended to magically prevent some dreaded event or situation

Question 14

Common Obsessions

Answer 14

> . Worrying that things are in the right order, e.g. symmetrically ordered books or that rugs are lined up i.e. symmetry
. Thoughts about being dirty or contaminated
. Thoughts about catastrophes like fires, illness or death
. Worrying about whether things are done properly e.g. if the doors are locked or windows closed
. Repulsion with bodily wastes
. Repetitive thoughts about lucky numbers
. Aggressive or horrific impulses e.g. to shout an obscenity in church
. Repetitive sexual imagery

Question 15

Common Compulsions

Answer 15

> . Washing your hands so often that they become sore and red
. Tidying your room to the extent that everything is perfectly ordered e.g. books lined up 2cm from end of the bookshelf
. Performing exercises in your mind e.g. counting backwards so as to not think about forbidden thoughts, repeating sentences, or phrases
. Repetitive checking behaviours e.g. checking every window and door is closed several times before going to bed
. Repetitive actions e.g. counting the lines in a floor rug with your foot each time you walk over it
. Obsessional slowness, taking excessive time to complete simple everyday tasks

Question 15

Common Compulsions

Answer 15

> . Washing your hands so often that they become sore and red
. Tidying your room to the extent that everything is perfectly ordered e.g. books lined up 2cm from end of the bookshelf
. Performing exercises in your mind e.g. counting backwards so as to not think about forbidden thoughts, repeating sentences, or phrases
. Repetitive checking behaviours e.g. checking every window and door is closed several times before going to bed
. Repetitive actions e.g. counting the lines in a floor rug with your foot each time you walk over it
. Obsessional slowness, taking excessive time to complete simple everyday tasks

Question 16

Body dysmorphic disorder (‘imagined ugliness’)

Answer 16

A preoccupation with some imagined defect in appearance
- This is not observable or appears slight to others
>. Comorbid with OCD 10%
>. Course lifelong
>. Onset – early adolescence through 20s
>. Reaction to a horrible or grotesque feature – persistent, intrusive thoughts, and compulsive behaviors e.g. checking mirror, excessive grooming
>. May be exaggeration of normal culturally sanctioned behavior
>. 76.4% access plastic surgery (centers on face) (1 study)
>. 8% - 25% of patients who request plastic surgery may have BDD

Question 17

Hoarding Disorder

Answer 17

Estimates of prevalence: 2% - 5% (double OCD); men = women
>. Excessively collecting and keeping items with minimal value, leading to cluttering and disruption of living space
>. Individuals usually begin acquiring things during their teenage years and often experience great pleasure, even euphoria, from shopping or otherwise collecting various items
>. Difficulty discarding\living with excessive clutter
>. OCD tends to wax and wane, whereas hoarding behavior can begin early in life and get worse with each passing decade

Question 18

Trichotillomania (Hair Pulling Disorder)

2.5 Excoriation (Skin Picking Disorder)

Answer 18

> . In DSMIV listed as impulse control DO’s, but share features with OCD of persistent thoughts, and repetitive and compulsive behaviors
. Trichotillomania: The urge to pull out one’s own hair from anywhere on the body, including the scalp, eyebrows, and arms

Excoriation (skin picking disorder) is characterized by repetitive and compulsive picking of the skin, leading to tissue damage
>. 1- 5%
>. Habit reversal training (i.e. aware of behaviour, substitute with a different behaviour e.g. chewing gum), show best results

Question 19

Treatment - Cognitive-behavioral therapy

Answer 19

> . Exposure and ritual prevention (ERP) i.e. prevent rituals and gradually expose or feared thoughts
. Facilitates reality testing
. Highly effective
. One study found that 86% of patients benefit
. No added benefit from combined treatment with drugs