In this section, we are going to be talking about the neurobiological theories of trauma, DSM-5 elements for PTSD, Reactive Attachment Disorder, Disinhibited Social Engagement Disorder, and OCD, clinical presentations of PTSD, and the different components of OCD.
Post-Traumatic Stress Disorder (PTSD)
It is our physiological make-up that we tend to have stronger memories for certain experiences that make an impact on us. Think about if you ate something very bitter, next time you remember that it’s bitter and would be less likely to eat it. This is called taste diversion learning.
Sometimes what we experienced is something that is outside of what we would experience normally. This can lead to trauma. When we think of PTSD, we tend to think of military combat. But, it is not limited to just that. Any traumatic experiences can lead to PTSD, whether it be life or death experiences or domestic violence, to name a few. In fact, the most common cause of PTSD is physical assault, not combat related. This number is the highest even when trauma is very underreported. So trauma is very common.
DSM-5 element of PTSD
There are eight elements that a patient must meet to be diagnosed with PTSD.
- Direct exposure to trauma: The person was exposed to death, serious injury, sexual violence either by direct exposure, witnessing, learning from close friend, or indirect exposure (think EMT.)
- Re-experiencing the trauma: The person re-experience that traumatic event over and over again through nightmares, flashbacks.
- Avoidance: The person attempts to avoid stimuli by avoiding thoughts or reminders
- Psychological Impact: The person needs to display at least two of the following:
- Overly negative thoughts
- Exaggerated blame
- Negative affect
- Loss of interest
- Feeling isolated
- Difficulty experiencing positive affect
- Physiological Impact: The person needs to display at least two of the following:
- Irritability or aggression
- Risky behavior
- Hypervigilance
- Difficulty concentrating and sleeping
- Duration: Symptoms must last at least 1 month.
- Quick note: Symptoms display within the 3 days to 1 month period of traumatic event are classified under acute stress.
- Functional impairment: Negatively impact daily life, work, or relationship
- No external factor: These symptoms are not due to medications or other illness
One thing I want to note is that trauma shows up differently in kids. It might present as intrusive distressing memories or dreams. The content might be a lot different from the actual event. What they share with adults is that they also practice avoidance as well.
Two most common specifiers for PTSD are dissociative specification (depersonalization or derealization) and delayed specification
Treatment of PTSD (APA Clinical Practice Guidelines)
Remember that in the treatment of PTSD, we don’t have really good medications for PTSDs. Because of this, try to avoid the use of medications and focus on behavioral therapies (strong evidence.) This can be in the form of cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy, or prolonged exposures.
The three therapies that are conditionally recommended are brief eclectic psychotherapy , eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy (NET)
If pharmacologic therapy is in consideration, it must be used cautiously. First option would be SSRIs.
Reactive Attach Disorder (RAD) – Child disorder only
DSM-5 elements
There are 7 elements:
- Emotionally withdrawn: The child displays consistent inhibited and emotionally withdrawn behaviors to caregivers or parents
- Social disturbance: The child must displays at least two of the following:
- Minimal social responsiveness to others
- Episodes of unexplained irritability, sadness, or fearfulness during non-threatening interactions
- Limited positive affect
- Social neglect or Deprivation: The child has experienced insufficient care and cannot form a stable connection. This can be due to neglect situation or raised in institution.
- Social neglect is the the presumed cause of emotional withdrawn
- Ruled out autism spectrum disorder
- Clear evidence before age of 5
- Development age of at least nine months
Common specifiers: persistent (if last more than 12 months) and severe (have all symptoms of the disorders and at high level)
Disinhibited Social Engagement Disorder – Child disorder only
DSM-5 Elements
There are five elements:
- Too trusting: The child is too trusting and actively approaches unfamiliar adults. These children would just leave and won’t check in with caregivers.
- Not because of ADHD: The behaviors are not limited to impulsivity
- History of insufficient care: The child has a history insufficient care like in the previous section
- Symptoms presumed to be due to insufficient care
- Developmental age of at least nine months
Common modifiers: persistent and severe
Obsessives-Compulsive Disorder (OCD)
There two primary components of OCD: obsessions and compulsive behaviors. Patients start off with having an obsession that is creating anxiety for them, so they come up with a behavior to relief the anxiety, and overtime this behavior becomes compulsive for them.
DSM-5 elements:
There are four elements:
- Presence of obsessions, compulsions, or both:
- Obsessions are persistent thoughts, urges, or impulses leading to anxiety or distress
- The anxiety gets so high that they try to do something about it (negative reinforcement)
- This leads to compulsion. Compulsion behaviors are repetitive behaviors that must performed in response to an obsession in order to reduce stress from the obsession.
- Time-consuming: This can create significant distress or impairment in life
- Rule out other factors: The symptoms are not due to medications or illness
- Rule out other mental illness: The symptoms are not associated with other mental disorder that may better explained the symptoms
Common modifiers: “with good or fair insight,” “with poor insight,” “with absent insight/delusional belief,” Tic-related
Medications that can cause symptoms of OCD include stimulants like Adderall
Medical conditions that may mimic the symptoms of OCD are autism, Asperger’s syndrome, brain tumor, endocrine condition, and tumor that hyper-secrete monoamines.
Do not confused OCD with OCPD. OCPD is Obsessive Compulsive Personality Disorder. This is the “neat” disorder or perfectionism.
Treatment of OCD
SSRIs like fluoxetine, fluvoxamine, paroxetine, and sertraline are approved for OCD.
Clomipramine (TCA) is approved as well.
We would want to start off with a cognitive therapy empirically and teach people how to calm down.
Anterior cingulotomy or anterior capsulotomy are only to be used as last resort. These reduce symptoms by about 50%, but don’t make the symptoms go away.