L.10 - OCD-related disorders Flashcards
(63 cards)
1
Q
Learning Objectives
A
- List and describe the symptomatology of different OCD-related disorders, including hoarding [paraphrasing]
- List the diagnostic criteria (DSM-V) of Body Dysmorphic Disorder (BDD) [paraphrasing]
- Describe the epidemiology of BDD in general population and cosmetic populations [paraphrasing]
- Describe pathophysiology, personality, cultural, and identity factors, trauma and the role of social media in BDD [paraphrasing]
- Describe differences/commonalities between BDD and substance abuse, OCD, and Anorexia Nervosa; as well as other disorders covered in the ACD course [paraphrasing]
- List and describe evidence-based treatments for BDD, both behavioral and pharmacological, and explain with which mechanisms in BDD they intervene [analyzing]
2
Q
Background info
- what are the OCD-related disorders?
A
- all OCD-related disorders are characterized by an irresistible urge to perform distreessing and time-consuming compulsive behaviors
1. Hoarding disorder
> persistent difficulty of disposing of belongings due to a strong need to save objects + suffering associated with disposing of them
2. Body dysmorphic disorder
> Preoccupation with one or more subjectively perceived defects or imperfections in one’s appearance that are not perceived by others or are considered by them to be insignificant
> This is associated with repetitive body-oriented behavior (e.g., grooming, seeking reassurance) or psychological activity (e.g., comparing one’s own appearance with that of others)
3. Trichotillomania
> Repeated pulling of the hair despite attempts to stop it
4. Skin-picking disorder
> Repeated plucking of the skin causing skin lesions, despite attempts to stop it
5. O-C or related disorder due to substance/medication
6. O-C or related disorder due to a somatic condition
7. Otherwise specified O-C or related disorder
8. The unspecified O-C or related disorder
3
Q
Background info
- what do OCD-related disorders have in common?
A
- big comorbidity between these different compulsive disorders, within individuals and family
- common genetic and neuropsychological processes underlie these different disorders
- cognitive impairments in motor inhibition (stop-signal task) and congitive flexibility (set shifting task) underlie all OCD-related disorders, but with differences
> e.g. Impaired response inhibition has been demonstrated with the stop-signal task in patients with trichotillomania, while extradimensional shifting (cognitive flexibility) was unaffected
(picture 1)
4
Q
Obsessive-compulsive & related disorders (OCRDS)
A
- in DSM-V there is one chapter dedicated to these disorders, while before they were together with anxiety disorders
- in DSM-V you have OCD, BDD, HD, Trichotillomania and Skin Picking disorder
- in ICD-11 you also have Hypochondriasis, Olfactory Reference Syndrome, and Tourette Syndrome
5
Q
what is Olfactory Reference Syndrome?
A
- very rare disease
- very very preoccupied with smelling bad
- they think they smell like urine, garbage, …
6
Q
BDD
- What is the core symptom?
- the role of Beauty
A
- people have belief that they have very ugly appearance, while others don’t see anything or really small defect
- all about beauty, and beauty matters (better grades, better work prospect, less court punishment, …)
- cosmetic industries really take advantage
> 8/9 years old posting videos of them taking hours to get ready and put on much make-up
> there are specific clinics for patients with complications from cosmetic procedures
7
Q
Video clip
- what are the main symptoms of BDD?
A
(- patients really get desperate and suicidal, because everyone tells them that there is nothing wrong with them and they feel like no one understands them and that they are alone)
- main symptom is comparing oneself to other people, comparing all different part of body (muscles, skin, hair, face shape, …)
- this leads to negative thoughts (people won’t find me attractive anymore)
- extreme self-awareness, and avoidance of social contact because of shame and fear of judgement about beauty, hygiene, …
- beauty related to self-worth (“If I have acne, I consider myself less”)
8
Q
Statistics
A
- facial features 80% (80% of people are focused on some parts of their face, but the focus can be on any body part)
- 5-7 body parts
- suicidal ideation 80%, attempts 25% (adolescents 44%)
- shame and disgust
9
Q
what are some compulsions found in BDD?
A
- because of these preoccupations, patients have this idea that they should completely get rid of their flaws
- this makes them engage in all different rituals, which takes so many hours every day
- exercising, checking mirror, social media, cosmetic treatments, make-up, …
10
Q
what are the criteria of BDD?
A
- preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others
- repetitive behaviors (e.g. mirror checking) or mental acts (e.g. comparing their appearance with that of others) in response to appearance concerns
- the preoccupation causes clinically significant distress or impairment in social, occupational or other areas of functioning
- the appearance preoccupation is not better explained by concerns with body or weight in an individual whose symptoms meet diagnositc criteria for an eating disorder
11
Q
Specifier: Muscle Dysmorphia and Insight
A
- Muscle Dysmorphia: e.g. people that think they are not strong enough, they don’t have enough muscles
> subtype of BDD, focus on muscles and posture
> over training and over use of anabolyc steroids (big problem)
> there are outpatients clinic experienced in patients using too much anabolyc stereoids
> many similarities with EDs - Insight: the patient is aware of reality of ideas
> up to 80% of patients with BDD have poor/absent insight → delusion of thinking
> they are completely convinced that the way they think about themselves is the way it is
12
Q
is BDD a new disorder?
A
- no, first case description of BDD was in 1896
- elaborate description of phenomenology and symptomatology
- called Dysmorphoria
13
Q
Comorbidity of BDD
A
- personality disorder: 57% (especially avoidant/dependent PD)
- Gender dysphoria: ?
- ASS: ?
- 75% MDD
- 40% Alcohol disorder
- 35% SAD
- 17% OCD
- 6% AN (30% EDs)
> in general high social anxiety, high rejection sensitivity, very perfectionistic, afraid of judgement
14
Q
BDD vs OCD - similarities
A
- genetic overlap
> 64% of genetic variability was similar between OCD and BDD
> OCD and simmetry obsessions have 82% shared genetic variability - physical past traumatic events
> e.g. sexual abuse, bullying, physical/emotinoal abuse, …
> more in BDD than OCD - sex ratio
> both have equal number of males and females, but in BDD females seek help more easily than men - traits of perfectionism
- body image disturbance (much more in BDD)
(picture 2)
15
Q
BDD vs OCD - differences
A
BDD
- little or no insight
- single
> BDD patients are much more often single than in relationship
> lot of sexual problems (ashamed of their body)
- sexual and emotional past traumatic events
- higher comorbidity with depression, suicidal ideation, SUD, social phobia
- Avoidant-personality disorder
OCD
- better insight
- OCD simmetry concernes
- Obsessive compulsive personality disorder (higher comorbidity)
(picture 2)
16
Q
Recap - similarities
A
- both are characterized by (obsessions and) compulsions
- sociodemographic features: gender ratio, comorbid depression and anxiety
- chronic and continuous illness course
- attentional biases (present in both)
17
Q
Recap - Differences
A
- level of insight: BDD patients have more often absent insight / delusional disorder (35%) compared to OCD (3%)
- BDD pts have more often SUD, increased suicidality, worsening of symptoms
- BDD pts have higher rates of emotional and sexual abuse
- BDD pts have more detailed perception, poorer facial affect perception and angry recognition bias
18
Q
BDD vs AN - similarities
A
- both are body image disturbances
- perfectionism and deficits in body size estimation
> delusionality: BDD pts are even more delusional compared to AN pts and controls - higher intensities of negative emotions, greater utilization of worrying
> worry as coping mechanisms - abnormalities in visuospatial processing and reward processing
19
Q
BDD vs AN - differences
A
- body weight / shape (AN) vs any other body part / more body parts (BDD)
> sometimes tricky, as patients come in with focus on their belly (shape) but not on weight (overlap) - BDD: more hopelessness, psychosocial impairment & familial burden
- BDD: higher delusionality, poorer QoL
- AN: lower self-esteem and increased levels of MDD
- increased insula-orbitofrontal cortex connectivity in AN, and increased occipital cortex connectivity in BDD
20
Q
BDD vs EDs
A
- muscle dysmorphia is the BDD subtype more closely related with EDs
> EDs are one of the symptoms of muscle dysmorphia
> very hard to get patients into hospital, because it’s much more common to train in the gym everyday now and this can be problematic especially for young people
(picture 3)
21
Q
prevalence of BDD
A
- general population: 1-2%
- adult community samples: more women
- psychiatric setting: equal sex ratio
- meta-analysis of 22 studies
→ structured interviews for diagnosis of BDD
> pooled prevalence: 11%
> cosmetic/dermatology settings: 20%
> mental health settings: 7.5%
> students and ballet dancers: 6.5%
= higher prevalences than general populations - BDD is under-recognized in mental-health care and it takes years to get a diagnosis after onset of symptoms
22
Q
screening questionnaires for BDD
A
- people with BDD don’t visit psychiatrists often because that’s not the help they think they need; “they don’t have mental problem, they have somatic problem”
- we need screening questionnaires to find this disorder in different outpatients clinics
- BDDQ
> 1st one to be validated
23
Q
Study of prevalence of BDD
A
- population: new patients at the outpatient clinic of dermatology, plastic syrgery and maxillofacial surgery (>1000)
- questionnaire: BDDQ-DV
- severity of defect assessed by surgeon, dermatologist, cosmetic doctor, …
> when there is severe defect, than BDD diagnosis does not apply - RQ: prevalence of BDD in different outpatients clinics
24
Q
Results
A
(picture 4)
- usual BDD prevalence found only in dentist population (control)
- at all other clinics, prevalence is much higher
- maxillofacial surgery has highest prevalence (10%)
! this study was replicated well afterwards → results are valid
25
Meta-analysis - prevalence of BDD
- dermatological surger: 15%
- plastic surgery: 16%
- cosmetic surgery: 22%
- cosmetic rinoplasty: 33%
26
Study 2 - BDD in adolescents
- 105 adolescents with acne (visited acne clinic)
- 13-24 y.o.
- 12% BDD prevalence (DSM-V criteria)
27
Pathophysiology of BDD - how does it develop?
- visual information processing
- neurotransmitters and brain circuits
- genes
- trauma
28
1. Visual information processing
- people with BDD have much more detailed visual information processing compared to controls
- not able to make global picture; focus on details
- overactivity in VVS (ventral visual system) compared to DVS (dorsal v.s.)
→ enhanced detail processing
→ correlated to severity of BDD symptoms
- when treating BDD patients, by treating visual information processing you are able to treat BDD symptoms
(picture 5)
29
2. Study 3 - BDD brain scan
- 12 BDD pts + 12 controls
- BDD patients have higher dopaminergic signal in the brain
> this is also similar to OCD (same results)
→ dopaminergic and seratonin systems are involved in BDD and OCD
- in basal ganglia there is increase in dopaminergic signal
30
3. Genes
- family members with BDD: 8%
- elevated rate of BDD first-degree relatives of probands with OCD compared to controls
> People with OCD (probands) are more likely to have close family members with BDD than people without OCD
- twin studies: 64% shared genetic vulnerability between BDD and OCD
31
Psychological factors
1- biases in selective attention
> eye-tracking studies show that pts with BDD are completely focused on disorder-relevant stimulus, self-referent and aesthetic details like symmetry
> some patients are completely focused there, some others instead try to look away all the time (different subtypes)
2- distorted cognition: perfectionistic thinking and maladaptive beliefs
> higher aesthetic standards, stronger beliefs about importance of attractiveness, tendency to form conclusions without sufficient information and misinterpretation of ambiguous social scenarios as negative and threatening
(she skipped this here)
3- memory deficits
> inaccurate coding and recall of face and body stimuli
31
Cultural, familial and identity factors
- higher prevalence of BDD symptoms: exposure to unrealistic beauty standards
> growing up in a family where appearance was very important
- high levels of family dysfunction / overprotection in families of individuals with OCDRDS
- family accomodation can reinforce the disorder, particularly in pediatric BDD
> family that gives reassurance, check the insecurities, ...
- gender:
> women: focus more on areas of body, increased distress, less illness insight, more safety behaviors, earlier age of onset
> men: worse overall functioning, more suicide attempt and success
- greater rates of BDD symptomatology in queer individuals and in racial ethnic minority individuals, and symptoms are more severe
31
Personality factors
- perfectionistic tendencies
- neuroticism
- behavioral/social inhibition
- unassertiveness
- rejection sensitivity
32
Trauma
Early childhood adversity
- physical abuse/neglect
- sexual trauma/abuse
- emotional neglect/abuse
- appearance and competence teasing
33
BDD and social media
- only few studies looked at social media's impact on BDD (more studies on body image)
- BDD symptoms increase when people are focused on social media, and viceversa
- judgement bias (focusing on people that are more attractive than themselves)
> this then gives depressive symptoms etc
34
what is the most often used intervention for BDD?
- most of the pts only want a cosmetic treatment, so it's hard to take them to clinicians
1. most common treatment → cosmetic treatment
2. medication
3. CBT
4. Neuromodulation
35
1. Cosmetic treatment
- 48-76% BDD pts have had cosmetic treatment before they visit psychiatrist
-26-66% have had different cosmetic procedures
- often not satisfied (lont-term)
> happy at the beginning, then dissatisfied
> focus of insecurity changes
- more procedures → worse prognosis
- new results?
> cosmetic procedures in new studies have shown that it's not all bad, sometimes it can help
36
study - results of cosmetic surgeries
- mostly negative results
> especially in the past, pts didn't improve after cosmetic treatment
(picture 6)
- now, results are more positive
> these studies had methodological limitations
→ only used questionnaires (no psychiatric/psychological assessment)
→ follow-up is really low (only short f.u.); the ones with longer f.u. have worse results
(picture 7)
37
Study - Brown 2024
- questionnaire specific to BDD in cosmetic setting (COPs)
- only 8 (/180) patients developped BDD after cosmetic procedure (increase in COPs)
> all the others improved
- now there is a specific guideline in Australia for every cosmetic doctor to screen for disorder
38
Medication
- SSRIs
> only 2 RCTs so far (50-60% pts decrease symptoms)
→ placebo-controlled discontinuation (you start with SSRIs, then some patients continue with placebo (40% relapse rate) and some with SSRIs (18% relapse rate)
- Clomipramine (tricyclic antidepressant that binds to seratonin)
- Antipsychotic addiction
> some patients are psychotic (they have delusional conviction), but antipsychotics haven't worked so far
> SSRIs + antipsychotics → small positive results
- Psilocybine
> + psychotherapy → 58% good response
39
CBT model
- the lecturer developped it in her center
- blue boxes: contributing factors to development of BDD
> genetics, envoronment, trauma, ...
> main problem: selective attention for BDD, which leads to negative thoughts about the self, which leads to anxiety, shame, then leading to BDD rituals and avoidance...
- green boxes: how clinic targets all specific symptoms
> specialized daycare program with 2 days per week for 4 months, with treatment for 8 patients
→ not easy to convince them to start treatment (ashamed to talk about it); but then once they start it works and talking about it helps
> thought exposure, exposure, response prevention, tension toleration, EMDR, new programs on personality characteristics (e.g. perfectionism), trauma therapy
40
how do you convince patients that treatment will work?
- there must be insight, the patient knowing that psychological treatment will help
- Theory A, theory B are taught to the pts
> theory A: the way the pts are experiencing symptoms right now (e.g. BDD rituals increase the problems)
> pts asked to leave theory A and go to theory B (BDD treatment)
- goal setting (!)
> agree with patients about goals they want to reach
> most pts have huge goals (I want to completely be okay with myself)
→ this is irrealistic, as BDD obsessions never fully go away, it's mostly about dealing with the compulsions and maladaptive behavior
- system involvement
- advantages and disadvantages of changing strategies: long vs short term
41
Cognitive therapy
- Goal: identifying and restructuring BDD-thoughts into helping thoughts
- changing the value attached to appearance
42
what does the reasoning process in BDD patients look like?
1. my nose looks ugly with a very red skin
2. other people will notice it
3. when other people look at my nose, they will have a negative judgement
4. if others don't like one thing, they will disapprove of me completely
- automatic thoughts and core beliefs are addressed in therapy
- in CT the value attached to appearance is changed, but how?
43
Cognitive distortions
- mind-reading, all-or-nothing thinking, jumping to conclusions and measuring with double standards
> these are the most common in BDD patients
- mind-reading: pts are focused on what they think other people think negatively about their appearance
> difficult to make a more general description of their appearance; they only see flaws and can't describe good characteristics of themselves
44
how do you change the value attached to appearance in CT?
- throught Thought Challenging
- most self-worth is based on appearance
- in exercise, you try to identify with patients other elements that contribute to self-worth
> e.g. being a good friend, ...
- multidimensional evaluation
> go to core belief of BDD patient (feeling of worthlessness) and ask pts to imagine a person in their life that is very valuable and one that is worthless
> then they have to write down that characteristics determine value and worthlessness
> then they have to score themselves on these dimensions, and they see that they score higher on specific dimesions compared to others
- G-schemes are helpful to address automatic thoughts and cognitive problems, to change it to helpufl thoughts
(picture 9 & 10)
45
Dysfunctional Assumptions
All these assumptions should be addressed in cognitive therapy!
> e.g. through G schemes, behavioral experiments, exposure, ...
1- Automatic thoughts
> focus on appearance
> convinced that others also negatively focus on the patient's appearance
2- Basal assumptions / core cognitions
> I am worthless
3- Conditional assumption
> if I do not look perfect, I will be rejected by others
> when I am not attractive, my life doesn't mean anything
4- Instrumental assumptions
> I have to look into the mirror, because I need to know how I look
> nobody is allowed to disapprove of my appearance, because I won't tolerate it
46
Exposure and response prevention
Exposure to Avoidance
- social situations
- public transport
- (eye) contact with others
- showing yourself without cap, glasses, make-up
> in clinic this is very important
> during these exercises, pts are not allowed to do BDD rituals
Response prevention
→ focused on decreasing BDD rituals
- mirror gazing / skin picking
- make-up / hair rituals
- confirmation behavior
- checking / comparing / social media
47
The mirror is not your friend (mirror retraining)
! in clinic they teach patients how to deal with mirrors / reflecting areas (avoidance or change in focus)
> pts are taught that mirrors are not their friends
~ minimize mirrors
> choose to look only in one part of the mirror that reflects part of body that they like
> slowly increase the parts of body they are able to look at in mirror
~ use at least a arm-width distance
> closer→ you can always see a spot they dislike
Mirror retraining:
- positive mirroring or objective describing
> ask pts to describe more neutral features (e.g. color of eyes)
→ this teaches them to shift attention to more general picture
- gradual exposure: start mirroring with a body part distant from the BDD focus
- you can also use this technique with pictures and movies
> try to describe general characteristics
48
CBT effectiveness results
- in outpatient clinic, at beginning of treatment SSRIs are offered together with CBT, as it decreases general anxiety related to treatment, making tr. more effective
- graph shows that symptoms decrease 40% (CBT) to 47% (CBT+meds)
(picture 11)
49
BDD and psychotherapy (general results)
- CBT: 48-84% pts respond, 15-25% no response
- trauma treatment & BDD
> imaginary rescripting
> showed positive results
- Supportive PT
> improved holistic and emotionally accurate processing
- Acceptance and Compassion-Focused Therapy
> improving self-image of people
> helps as people are afraid of starting exposure therapy directly
50
the unmet treatment need in BDD
- 60% BDD patients get no life treatment
- 22% only receive medication or CBT
- 13% of pts with CBT had received all components
~ clinic offers more experienced treatment, which works better than just CBT
~ individual-level treatment barriers: shame and stigma
51
Neuromodulation
- rTMS & DBS
- in clinic they did first rTMS treatment worldwide in patients with BDD
> patients had BDD and depression
> targeted area: dorsolateral prefrontal cortex
> open-label case series (no sham control condition)
→ 4/6 pts with BDD symptoms really improved
→ 5/6 pts with depression really improved
! promising results !
(picture 12)
52
rTMS and BDD
- rTMS + medication
> 47% decrease of BDD symptoms
> 62% decrease of depressive symptoms
- peak-effect after 10 sessions (2 weeks)
> problem of study was lack of follow-up
→ risk of relapse if rTMS not continued
- 2 non-responders → low insight, increased suicidality
53
Take-away messages
- BDD is poorly recognized
> much research is still missing
- BDD has a high prevalence, especially in cosmetic clinics and prevalences are increasing
- Multivariate causes of BDD: genes, trauma, visual information processing, psychological and personality factors, culture and social media
- (group)CBT is highly effective together with medication (SSRIs)
- neurostimulation (rTMS and DBS) and trauma treatment are promising
54
Article flashcards
55
The nature of Body Dysmorphic Disorder
- excessive and persistend preoccupation with perceived flaws in physical appearance (mostly facial features)
! some individuals cannot pinpoint their concerns to specific aspects of their appearance
> instead, they describe general appearance worries (e.g. I look ugly)
- pts engage in compulsive behaviors to:
> check
→ mirrors, selfies, touching flaws
> camouflage
→ concealing with make-up, clothes, or other body parts
> correct their perceived defects
→ grooming routines, skin-picking, and cosmetic treatments
> + avoidance
→ avoid reflections, not leave the house
56
BDD - origin & general statistics
- typically develops during teenage years
> 2/3 of adults retrospectively trace it back to adolescence
- poor QoL, high rates of occupational impairment, unemployment, social isolation
- in young people: reduced academic performance, dropping out of school, social withdrawal
- high comorbidity with depression, SAD, OCD, & EDs
- high rates of suicidality
> 25% attempts suicide
> 80% have suicidal ideation
> 50% self-harm
- many lack insight
> still debate whether low insight or delusionality
! levels of BDD are not static, they vary greatly over short time intervals and improve with treatments
57
prevalence
- 2% of population
- more common in cosmetic settings
> 1/5 people with rhinoplasty have BDD
- among young people, many more females than males, but in adulthood difference decreases a lot
→ indicates that females have earlier onset
> males more muscle dysmorphia
> females more hips, breasts, body hair and legs
- Asian participants more likely to have concerns about dark skin and straight hair
> white participants more concerns over body shape
→ type of concern depends on ethnic group
58
Assessment
- severly overlooked and misdiagnosed
> many similarities with other disorders
- BDD-Y-BOCS is the gold-standard clinician administered measure of BDD
- for young people, it's important to have informants
- 75% seek cosmetic procedures
> BDD symptoms do not improve following intervention (dissatisfaction, disappointment and deterioration of mental health)
> DIY surgery (high risk)
59
comorbidities
(similarities & differences)
(pictures 13)
60
treatment
- CBT is effective (also in reducing associated depression)
> around 10 sessions are enough, but for young people and to prevent relapse, more sessions are better
- higher baseline symptom severity → less improvement in BDD symptoms
- higher motivation to change, greater treatment expectations, greater treatment credibility, expectation of improvement, better insight, shorter duration of BDD, and lower levels of depression → better outcome prediction
- SSRIs given especially if CBT alone is not sufficient
> better if in combination, but work also as standalone treatment
(picture 14)
61
Barriers to Access
- only 15-23% of adults with BDD have received an accurate diagnosis
- 17% CBT, 34% SSRIs
- Barriers:
> personal characteristics (shame, lack of insight)
> broader cultural and societal issues (stigma)
> constraints within health care settings (lack of expertise and resources for accurate diagnosis and assessment)
> lack of trained therapists and costs associated with treatment
