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OCD and Trauma-Related Conditions: Patterns, Stress Reactions, and Therapy
Abnormal Psychology · Chapter 11: Anxiety-Based Disorders: Origins and Therapeutic ApproachesSection 11.4 · lesson 42 of 9719 min · free with a free account
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In this lesson
Two families that left the anxiety chapter, and why the move made sense.
- Define obsessions and compulsions and trace the cycle
- Explain why intrusive thoughts are near-universal
- Describe the four clusters of post-traumatic stress disorder
- State accurately what is known about course and recovery
Transcript
Everything said in the video, section by section (2,458 words). Read along, or search it.
Anxiety-Based Disorders: Origins and Therapeutic Approaches
OCD and Trauma-Related Conditions: Patterns, Stress Reactions, and Therapy
Most people have had a thought that disturbed them, and dismissed it. The research says that experience is near-universal, and its content is unremarkable. So what separates that from a condition? Not the thought. The reading of it. This section covers two families that both left the anxiety chapter. Obsessive-compulsive disorder, and the trauma-related conditions. We look at why they moved, and what the move tells us about each. Then obsessions, compulsions, and the cycle that keeps them running. Then the four clusters of post-traumatic stress disorder, and what usually happens after an event.
Reclassified
Why These Two Families Moved
Both families appeared in the anxiety chapter of earlier editions of the classification. In the current text revision they occupy two separate chapters of their own. Obsessive-compulsive and related disorders. And trauma- and stressor-related disorders. The reasoning is different in each case, and worth understanding rather than memorizing. Obsessive-compulsive disorder was separated because of what it resembles. It shares more with conditions marked by repetitive behavior and difficulty inhibiting it. Body dysmorphic disorder, hoarding disorder, and body-focused repetitive behaviors. Anxiety is present, but the organizing feature is the repetitive act. And the person's inability to stop performing it. The trauma-related conditions were separated for a different reason entirely. They are defined by something no other chapter requires. An identifiable external event. They are the only conditions grouped by their cause rather than their presentation. And those presentations are heterogeneous. Some predominantly fearful, some low in mood, some angry or numb. That is a poor fit for an anxiety grouping. One note before we go on. This material is educational, and is not a basis for diagnosis. It discusses obsessional thinking and traumatic events at the level of general categories only.
Obsessions
The Intrusion Is Not the Problem
Obsessions are recurrent, persistent thoughts, images, or urges. They are experienced as intrusive and unwanted, and they cause marked distress. The person tries to ignore them, suppress them, or neutralize them with something else. The defining quality is that obsessions are ego-dystonic. That means experienced as alien to the person's values and sense of self. Something happening to them, rather than something they are choosing to think. This is diagnostically central. A person who wants something is not obsessing about it. The distress arises precisely because the content is contrary to what the person values. Now the most important single fact in this section, and it changes everything. Research beginning with Stanley Rachman and Padmal de Silva, in nineteen seventy-eight. It has been replicated many times since. Unwanted intrusive thoughts occur in the great majority of people with no condition at all. Including thoughts whose content is disturbing or otherwise unacceptable to the person having them. Researchers compared intrusions from people with the condition and people without it. The content was largely indistinguishable. What differed was the interpretation. Without the condition, a person finds the intrusion odd, and dismisses it as mental noise. With the condition, the same intrusion is read as significant. As revealing something about their character, as indicating danger, or as carrying a responsibility to act. The clinical implication follows directly. The intrusion is not the problem. It is not what treatment targets. The appraisal is.
Compulsions
Four Dimensions, and One That Breaks the Pattern
Compulsions are repetitive behaviors or mental acts a person feels driven to perform. In response to an obsession, or according to rigid rules. They are aimed at reducing distress or preventing a feared outcome. While being either not realistically connected to that outcome, or clearly excessive. Four symptom dimensions cover most of what is seen. Contamination. The theme is dirt, germs, illness, or contamination by contact. The compulsions are washing, cleaning, avoidance, and decontamination routines. The feared outcome is becoming ill, or being responsible for someone else becoming ill. Harm and responsibility. The theme is causing harm through carelessness or failure to check. Checking locks and appliances, retracing steps, seeking reassurance that nothing went wrong. Symmetry and ordering. A need for things to be even, aligned, or right. Now look at the feared outcome column for that row, because it breaks the pattern. There is frequently no specific outcome at all. Only an intolerable sense of incompleteness. That matters. A clinician who assumes every compulsion prevents a catastrophe will misread it. And it shows the cycle can run on distress alone. Taboo themes are intrusions contrary to the person's own values. No content is given here. One more thing, and it is routinely missed. Compulsions can be entirely mental. Mentally reviewing events, silently repeating phrases, counting, arguing against an intrusion. A person may report no compulsions while performing mental ones continuously. And reassurance-seeking is a compulsion too, performed through another person.
The Diagnosis
Thresholds, Insight, and a Word Misused
The disorder requires obsessions, compulsions, or both. Either alone will do. Two further requirements do the diagnostic work. The symptoms must be time-consuming, or cause significant distress or impairment. The conventional time threshold is more than an hour a day. And they must not be better accounted for by another condition, a substance, or a medical cause. An insight specifier records how far the person recognizes the beliefs as untrue. Good or fair insight. Poor insight. Or absent insight, with delusional beliefs. That specifier matters, because poorer insight is associated with a more difficult course. It is also where the boundary with a psychotic presentation becomes genuinely difficult. Now something that needs stating plainly, without qualification. Some people experience intrusions of an aggressive, sexual, or religious nature. Profoundly contrary to their own values. Such thoughts do not indicate desire. They are distressing precisely because they conflict with what the person wants and values. They do not indicate intent, and they are not predictive of action. That is well established, and it is not a reassurance offered out of kindness. These themes are among the most likely to go unreported, often for years. Late presentation is common for exactly that reason. Finally, a note on the popular usage. OCD is widely used as an adjective for tidiness. That misrepresents the condition. This is not a personality style or a fondness for order. It is a condition in which someone is driven to perform acts they do not want to perform.
The Cycle
Why the Belief Is Confirmed Every Time
The engine of the cycle is negative reinforcement, from five point one. The compulsion is followed by a reduction in distress, and that strengthens it. Follow the loop round. An intrusive thought arrives. It is appraised as significant, rather than dismissed. Distress follows, intense and urgent. The compulsion is performed, and relief arrives. Real relief, and brief. Now notice where the arrow returns. Not to the intrusion, which cannot be removed. It returns to strengthen the appraisal, which is exactly what is accessible. Two consequences are worth stating explicitly. First, the relief is genuine. The person is not simply being irrational in performing the compulsion. Second, because the compulsion always intervenes, something never gets discovered. The person never finds out that the distress would have fallen on its own. Or that the feared outcome would not have occurred anyway. So the belief that the compulsion was necessary is confirmed every single time. This is the disconfirmation problem of eleven point two, in a different form. And it is the reason response prevention is the active ingredient in treatment.
Contributions
What Turns an Intrusion Into an Obsession
Four cognitive contributions turn an ordinary intrusion into an obsession. Inflated responsibility is the belief that one has a special obligation to prevent harm. And that failing to prevent harm is equivalent to causing it. Paul Salkovskis proposed in nineteen eighty-five that this appraisal makes the conversion. It explains why checking dimensions are so often organized around harm to others. Thought-action fusion is treating a thought as morally equivalent to the act. Or as making the act more likely to occur. This is the mechanism that makes taboo intrusions so distressing. The thought is taken as evidence about character. Overestimation of threat inflates both the likelihood and the severity of the feared outcome. And intolerance of uncertainty, introduced in eleven point one, is central here. The compulsion is an attempt to reach certainty. But certainty about a negative, that nothing bad happened, is unobtainable. Which is exactly why checking can continue indefinitely. On the biological side, cortico-striatal circuitry has been consistently implicated. Those are loops connecting frontal cortical regions with the basal ganglia. Altered activity is reported, with changes following successful treatment of either kind. State that as an association, and stop there. It does not establish that the condition is caused by the circuitry rather than reflected in it.
After an Event
The Only Diagnosis With an Entry Event
The trauma-related conditions require an exposure criterion, and this is unusual. The person must have been exposed to actual or threatened death, serious injury, or sexual violence. There are four routes. Experiencing it directly. Witnessing it happen to another person. Learning that it happened to a close family member or friend. Or repeated exposure to distressing details in the course of professional duties. That last route explicitly excludes exposure through media for non-occupational purposes. Post-traumatic stress disorder is organized into four symptom clusters. Intrusion is involuntary re-experiencing. Memories arriving unbidden, nightmares, flashbacks. Also intense distress or physical reactions to reminders. Avoidance is deliberate effort to avoid internal reminders, or external ones. People, places, conversations, and activities. The third cluster is negative alterations in cognition and mood. Persistent negative beliefs about oneself, others, or the world. Distorted blame. Detachment. Inability to feel positive emotions, and inability to recall aspects of the event. The fourth is alterations in arousal and reactivity. Irritability, hypervigilance, exaggerated startle, concentration difficulty, disturbed sleep. All four clusters must be present. That requirement is where recognition often fails. Someone presenting with irritability and poor sleep may be assessed for a mood condition. And never asked about the event, or about the intrusions.
Windows And Courses
Timing, Subtypes, and What Usually Happens
Timing separates the two diagnoses in this family. Post-traumatic stress disorder requires the picture to persist more than one month. A delayed expression specifier applies where the full picture appears at least six months after. Acute stress disorder covers substantially the same territory in a shorter window. From three days to one month after exposure. It requires a specified number of symptoms drawn from across the same domains. But without requiring representation in every cluster. The relationship between the two is more often misunderstood than not. Acute stress disorder is not simply an early form of the persistent condition. And it is not a reliable predictor of it, in either direction. Many people who meet the acute description recover and never develop the persistent condition. And many who develop the persistent condition did not meet it in the first month. The category exists mainly to identify people who are severely distressed early. Now the fact that should be stated before anything else about this family. Most people exposed to a traumatic event do not develop a persistent psychological disorder. Distress in the days and weeks afterward is common and expected. For the majority it declines over subsequent weeks and months, without treatment. That is not consolation offered at the end of a difficult topic. It is the finding. Risk is associated with severity and duration of exposure, and with prior difficulty. And, importantly, with what happens afterward. Social support, subsequent life stress, and how others respond to the disclosure. That last group matters clinically, because it is modifiable. The event is not.
Explanation
Three Accounts, Each Covering Different Clusters
Three explanatory accounts, and each covers different parts of the picture. Conditioning and avoidance. Cues present during the event become conditioned stimuli. They come to elicit fear, and avoiding them is negatively reinforced, which prevents extinction. That accounts well for the intrusion and avoidance clusters. It accounts much less well for the alterations in cognition and mood. Memory processing. This was developed in work by Anke Ehlers and David Clark, published in two thousand. The proposal is that the trauma memory is encoded in a fragmented form. Strong in sensory detail, and weak in the time-and-place information that marks it as past. That explains something people describe often and find hard to convey. Intrusions arrive as present-tense experience, rather than as recollection. They are not being recalled, because what would locate them in the past is weak. And that supplies the rationale for treatments working directly on the memory. Appraisal. The meanings made of the event, and of its aftermath. About one's own conduct, about what the event proves regarding safety, about what symptoms indicate. These are proposed as central maintaining factors. That accounts for the third cluster, and it explains something otherwise puzzling. Two people exposed to a comparable event can differ enormously in outcome.
Treatment
Two Families, Two Approaches, One Principle
For obsessive-compulsive disorder, the leading psychological approach is exposure and response prevention. The rationale follows directly from the cycle. The person encounters the situations and thoughts that trigger obsessional distress. While not performing the compulsion. So they discover two things. That the distress falls on its own. And that the feared outcome does not follow. The response prevention component is what does the work. Exposure with the compulsion still performed leaves the belief entirely intact. That is the same reasoning as safety behaviors in eleven point two. Cognitive work on inflated responsibility and thought-action fusion is typically included. For post-traumatic presentations, two families of approach have the strongest evidence. Trauma-focused cognitive-behavioral therapies, and structured memory-processing therapies. They work on the memory, so it becomes a coherent account located in the past. On the appraisals of the event and its aftermath. And on the avoidance that prevents both. This is demanding work, delivered by clinicians trained in it. Unguided self-directed exposure to traumatic memories can worsen the condition. Medication is described by class only, with no drug names, doses, or regimens anywhere. Finally, a note on debriefing, because the evidence surprised people. Single-session debriefing delivered to everyone shortly after an event was widely used for years. It is not supported by the evidence, and for some people it is unhelpful. One proposed explanation is that it interrupts natural recovery in the majority. Current practice favors practical support, monitoring, and treatment for those who develop difficulties.
What To Carry
Durable Claims From This Section
Gather this into claims worth keeping. Unwanted intrusions are near-universal, and their content is largely indistinguishable. The appraisal is what treatment targets, not the thought. Obsessions are ego-dystonic, so a person who wants something is not obsessing about it. Covert compulsions and family reassurance must be included, or treatment will appear to fail. The relief from a compulsion is genuine. That is why the behavior persists. All four post-traumatic clusters are required, and single-cluster presentations get misread. Most people exposed to a traumatic event do not develop a persistent disorder. Acute stress disorder does not reliably predict the persistent condition in either direction. One last thing, which is about services rather than treatment. Trauma-informed practice applies whether or not a person has a diagnosis. Ask what happened rather than what is wrong, and accept the detail the person chooses to give.
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