COMPETENCY APPRAISAL I

BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

complicated by panic attacks or other

features that are the focus of the anxiety .
PSYCHOLOGICAL DISORDER PART I But in generalized anxiety disorder, the
focus is generalized to the events of
everyday life. Therefore, we consider
TOPIC OVERVIEW generalized anxiety disorder first.
A.​ Anxiety Disorders
a.​ Generalized Anxiety Disorder A1 GENERALIZED ANXIETY DISORDER
b.​ Panic Disorder
c.​ Agoraphobia
d.​ Specific Phobia ●​ characterized by excessive,
e.​ Social Anxiety Disorder uncontrollable worry about various
f.​ Separation Anxiety Disorder aspects of daily life, such as work, health,
g.​ Selective Mutism and social interactions. The worry is
B.​ Trauma and Related Stressors - persistent and difficult to control, often
Related Disorder accompanied by physical symptoms like
a.​ Posttraumatic Stress Disorder restlessness, fatigue, and muscle tension.
b.​ Joneses Case ●​ A person with GAD might constantly
c.​ Adjustment Disorders worry about their job security despite
d.​ Attachment Disorders positive performance reviews. They may
C.​ Obsessive Compulsive and Related struggle to sleep at night, experience
Disorders muscle tension, and find it difficult to
a.​ Obsessive-Compulsive Disorder focus on daily tasks due to their
b.​ Body Dysmorphic Disorder persistent anxiety.
c.​ Hoarding Disorder
d.​ Trichotillomania DIAGNOSTIC CRITERIA FOR
e.​ Excoriation GENERALIZED ANXIETY DISORDER
D.​ Somatic Symptom and Related
Disorder
a.​ Illness Anxiety Disorder A. Excessive anxiety and worry
b.​ Conversion Disorder (apprehensive expectation) occurring more
c.​ Factitious Disorder days than not for at least 6 months about a
d.​ Physiological Factors Affecting number of events or activities (such as
Other Medical Conditions work or school performance).
E.​ Dissociative Disorders
a.​ Depersonalization - B. The individual finds it difficult to control
Derealization Disorder the worry.
b.​ Dissociative Amnesia
c.​ Dissociative Identity Disorder C. The anxiety and worry are associated
with at least three or more of the following
six symptoms (with some symptoms
A ANXIETY DISORDERS present for more days than not for the past
6 months)
●​ Disorders traditionally grouped together
as anxiety disorders include generalized Note: only one item is required in children:
anxiety disorder, panic disorder, and 1. Restlessness or feeling keyed up or on edge
agoraphobia, specific phobia and social 2. Being easily fatigued
anxiety disorder and selective mutism. 3. Difficulty concentrating or mind going
These specific anxiety disorders are

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 COMPETENCY APPRAISAL I
BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

5.​ Overactive amygdala and prefrontal

blank
cortex, contributing to excessive worry.
4. Irritably
5. Muscle tension
6. Sleep disturbance (difficulty falling or TREATMENTS
staying asleep or restless, unsatisfying sleep)
●​ Cognitive-Behavioral Therapy (CBT)
D. The anxiety, worry or physical symptoms
-​ Gold standard treatment for GAD.
cause clinically significant distress or
-​ Helps individuals recognize and
impairment in social, occupational, or other
challenge maladaptive thoughts
important areas of functioning.
and develop coping strategies.
-​ Techniques: Cognitive
E. The disturbance is not due to the direct
restructuring, exposure therapy,
physiological effects of a substance (e.g., a
relaxation training.
drug of abuse, a medication) or a general
medical condition (e.g., hyperthyroidism) .
●​ Medications
-​ Selective serotonin reuptake
F. The disturbance is not better explained
inhibitors (SSRIs) (e.g., fluoxetine,
by another mental disorder (e.g., anxiety or
paroxetine) and
worry about having panic attacks in panic
serotonin-norepinephrine
disorder, negative evaluation in social
reuptake inhibitors (SNRIs) (e.g.,
anxiety disorder).
venlafaxine, duloxetine).
-​ Benzodiazepines (e.g., diazepam,
lorazepam) are sometimes used
STATISTICS
short-term but carry risks of
dependence.
●​ Lifetime prevalence of GAD: 5-6% of the -​ Buspirone, a non-benzodiazepine
general population. anxiolytic, can also be prescribed.
●​ 12-month prevalence: 2.9% in adults and
0.9% in adolescents (DSM-5).
A2 PANIC DISORDER
●​ More common in women than men
(about 2:1 ratio).
●​ Onset often in early adulthood, with ●​ Panic Disorder is characterized by
symptoms worsening during periods of recurrent, unexpected panic
stress. attacks—sudden episodes of intense fear
or discomfort that peak within minutes.
These attacks are often accompanied by
CAUSES
physical symptoms such as rapid heart
rate, dizziness, shortness of breath, and a
1.​ Chronic stress (work, relationships, feeling of losing control.
finances) ●​ A person with Panic Disorder may
2.​ Early trauma or adverse childhood suddenly experience a racing heart,
experiences. dizziness, and shortness of breath while
3.​ Genetic predisposition (heritability driving. Even after the episode passes,
estimated at 30%). they may become fearful of future
4.​ Dysfunction in GABA, serotonin, and attacks and start avoiding driving
norepinephrine neurotransmitter altogether.
systems.

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 COMPETENCY APPRAISAL I
BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

3.​ Cognitive misinterpretation of bodily

DIAGNOSTIC CRITERIA FOR
sensations (“I’m having a heart attack!”).
PANIC DISORDER
4.​ Anxiety sensitivity (hypersensitivity to
physiological changes).
5.​ Learned fear responses from past panic
A. Recurrent unexpected panic attacks are attacks.
present

B. At least one of the attacks has been TREATMENTS

followed by 1 month or more of one or both
of the following (a) persistent concern or
●​ Cognitive-Behavioral Therapy (CBT)
worry about additional panic attacks or
-​ Panic Control Treatment (PCT):
their consequences (e.g., losing control,
Exposes patients to feared
having a heart attack, "going crazy”), or (b)
sensations and helps them
a significant maladaptive change in
reinterpret bodily reactions.
behavior to the attacks (e.g., behaviors
-​ Interoceptive exposure:
designed to avoid having panic attacks,
Simulating panic attack
such as avoidance of exercise or unfamiliar
symptoms to reduce fear
situations.
response.
-​ Cognitive restructuring:
C. The disturbance is not attributable to the
Changing catastrophic thoughts
physiological effects of a substance (e.g.,
about panic attacks.
hyperthyroidism, cardiopulmonary
disorder).
●​ Medications
-​ SSRIs (e.g., fluoxetine, sertraline)
D. The disturbance is not better explained
and SNRIs (e.g., venlafaxine).
by another mental disorder (e.g., the panic
-​ Benzodiazepines (e.g.,
attacks do not occur only in response to
alprazolam, clonazepam) are
feared social situations, as in social anxiety
effective but risky for long-term
disorder).
use due to dependence.

STATISTICS A3 AGORAPHOBIA

●​ Lifetime prevalence: 4.7% of the general ●​ Agoraphobia is an intense fear of being

population. in situations where escape might be
●​ Onset typically occurs in late difficult or help may not be available
adolescence to early adulthood. during a panic attack or embarrassing
●​ More common in women (2:1 ratio). event. It often leads to avoidance of
public places.
●​ A person with agoraphobia may avoid
CAUSES crowded shopping malls, public
transportation, or even leaving their
1.​ Major stressors (loss, trauma, major life home due to fear of having a panic
changes). attack and being unable to escape.
2.​ Childhood experiences of
unpredictability or overprotective DIAGNOSTIC CRITERIA FOR
parenting. AGORAPHOBIA

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 COMPETENCY APPRAISAL I
BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

disorder) and are not related exclusively to

A. Marked fear or anxiety about two or obsessions (as in obsessive-compulsive
more of the following five situations: Public disorder), perceived deficits or flaws in
transportation, open spaces, enclosed physical appearance (as in body
places, standing in line or being in crowd, dysmorphic disorder), reminders of
being outside the home alone. traumatic events (as in posttraumatic
disorder), or fear of separation (as in
B. The individual fears or avoids these separation anxiety disorder).
situations due to thoughts that escape
might be difficult or help might not be
available in the event of developing STATISTICS
panic-like symptoms or other
incapacitating or embarrassing symptoms
(e.g., fear of falling in the elderly, fear of ●​ Lifetime prevalence: ~1-2% of the
incontinence). population.
●​ More common in women (2:1 ratio).
C. The agoraphobic situations almost ●​ Often develops after repeated panic
always provoke fear or anxiety. attacks but can occur without panic
disorder.
D. The agoraphobic situations are actively
avoided, require the presence of a CAUSES
companion, or are endured with intense
fear or anxiety.
1.​ Strong overlap with Panic Disorder.
E. The fear or anxiety is out of proportion to 2.​ Behavioral avoidance: Avoiding
the actual danger posed by the situations that previously triggered panic
agoraphobic situations, and to the attacks.
sociocultural context. 3.​ Genetic predisposition and
neurotransmitter imbalances.
F. The fear, anxiety or avoidance is
persistent, typically lasting for 6 months or TREATMENTS
more.

G. The fear, anxiety, or avoidance causes ●​ Cognitive-Behavioral Therapy (CBT)

clinically significant distress or impairment -​ Exposure therapy: Gradual
in social, occupational or other important exposure to feared situations.
areas of functioning. -​ Cognitive restructuring to
change irrational beliefs
H. . If another medical condition (e.g.,
inflammatory bowel disease, Parkinson’s ●​ Medications
disease) is present, the fear, anxiety, or -​ SSRIs and SNRIs for long-term
avoidance is clearly excessive. management.
-​ Benzodiazepines for short-term
I. The fear anxiety, or avoidance is not relief.
better explained by the symptoms of
another mental disorder, e.g., the A4 SPECIFIC PHOBIA
symptoms are not confined to specific
phobia, situational type; do not involve only
social situations (as in social anxiety

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 COMPETENCY APPRAISAL I
BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

●​ Specific Phobia is an intense, irrational

panic like symptoms or other
fear of a particular object or situation
incapacitating symptoms (as in
that leads to avoidance behavior and
agoraphobia); objects or situations related
significant distress. The fear is excessive
to obsessions (as in obsessive-compulsive
and disproportionate to the actual
disorder); reminders of traumatic events (as
danger posed by the object or situation.
in posttraumatic stress disorder);
●​ A person with a phobia of spiders
separation from home or attachment
(arachnophobia) might panic upon
figures (as in separation anxiety disorder);
seeing a small spider and refuse to enter
or social situations (as in social anxiety
rooms where they think a spider might
disorder).
be present.
Specific type:
DIAGNOSTIC CRITERIA FOR 1. Animal
SPECIFIC PHOBIA 2. Natural environment (e.g., heights, storms,
and water)
3. Blood-injection-injury
A. Marked fear or anxiety about a specific 4. Situational (e.g., planes, elevator, or
object or situation (e.g., flying, heights, enclosed places)
animals, receiving an injection, seeing 5. Other (e.g., phobic avoidance of situations
blood). that may lead to choking, vomiting, or
contracting an illness; or in children,
B. The phobic object or situation almost avoidance of loud sounds or costumed
always provokes immediate fear or anxiety. characters
Note: In children, the anxiety may be
expressed by crying, tantrums, freezing, or
clinging. STATISTICS

C. The phobic object or situation is actively

●​ Lifetime prevalence: ~12% of the general
avoided or endured with intense fear or
population.
anxiety.
●​ More common in women than men (2:1
ratio).
D. The fear or anxiety is out of proportion
●​ Onset usually in childhood but can
to the actual danger posed by the specific
develop at any age.
object or situation, and to the sociocultural
●​ Most common anxiety disorder but
context.
many do not seek treatment due to
E. The fear, anxiety or avoidance is avoidance strategies.
persistent, typically lasting for 6 months or
more. CAUSES

F. The fear, anxiety or avoidance causes

clinically significant distress or impairment 1.​ Genetic predisposition (heritability
in social, occupational or other important ~30%).
areas of functioning. 2.​ Overactive amygdala (fear-processing
center in the brain).
G. The disturbance is not better explained 3.​ Classical conditioning – A person may
by the symptoms of another mental develop a phobia after a traumatic
disorder, including fear, anxiety, and experience (e.g., bitten by a dog → fear of
avoidance of: situations associated with dogs).

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

4.​ Vicarious learning – Observing someone Even when forced to speak, they may
else’s fear response (e.g., seeing a parent experience a racing heart, sweating, and
scream at a snake). trembling.
5.​ Cognitive biases – Overestimating
danger or harm (e.g., “If I see a spider, it
DIAGNOSTIC CRITERIA FOR
will bite and kill me”).
SOCIAL ANXIETY DISORDER

TREATMENTS
A. Marked fear or anxiety about one or
more social situations where scrutiny by
●​ Cognitive-Behavioral Therapy (CBT)
others is possible (e.g., public speaking,
-​ Exposure Therapy (Systematic
meeting new people, eating in public).
Desensitization): Gradual,
controlled exposure to the feared
B. The individual fears acting in a way that
object while practicing relaxation
will be negatively evaluated (e.g.,
techniques.
humiliation, embarrassment, rejection).
-​ Flooding: Intense, prolonged
exposure to the feared stimulus
C. The social situations almost always
until anxiety naturally decreases.
provoke fear or anxiety.
-​ Cognitive Restructuring:
Changing irrational beliefs about
D. The situations are avoided or endured
the feared object or situation
with intense distress.
●​ Virtual Reality Exposure Therapy (VRET)
-​ Uses computer simulations to
E. The fear is out of proportion to the actual
expose individuals to feared
threat.
objects in a controlled
environment.
F. The symptoms persist for six months or
-​ Medications (Typically not
more.
first-line treatment
●​ Medication
G. The fear/anxiety causes significant
-​ Beta-blockers (e.g., propranolol)
distress or impairment in daily life (e.g.,
to reduce physical symptoms of
work, school, relationships).
anxiety.
-​ Benzodiazepines (short-term use
H. The symptoms are not due to substance
for severe cases).
use, a medical condition, or another mental
disorder (e.g., autism spectrum disorder).
A5 SOCIAL ANXIETY DISORDER
I. The fear, anxiety or avoidance is not
better explained by the symptoms of
●​ Social Anxiety Disorder (SAD), also another mental disorder, such as panic
known as Social Phobia, is characterized disorder (e.g., anxiety about having a panic
by an intense fear of social or attack) or separation anxiety disorder (e.g.,
performance situations where the fear of being away from home or a close
individual worries about being judged, relative).
embarrassed, or humiliated. This fear
leads to avoidance of social situations or J. If another medical condition (e.g.,
enduring them with extreme distress. stuttering, Parkinson’s disease, obesity,
●​ A person with social anxiety may avoid disfigurement from burns or injury) is
speaking in meetings at work, fearing present, the fear, anxiety or avoidance is
they will say something embarrassing.

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 COMPETENCY APPRAISAL I
BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

-​ Selective serotonin reuptake

clearly unrelated or is excessive.
inhibitors (SSRIs) (e.g., sertraline,
paroxetine).
Specifier: Performance-Only – When anxiety
-​ Serotonin-norepinephrine
is limited to public speaking or performance
reuptake inhibitors (SNRIs) (e.g.,
situations.
venlafaxine).
-​ Beta-blockers (e.g., propranolol)
for performance anxiety
STATISTICS
-​ Benzodiazepines (short-term use
for severe cases)
●​ Lifetime prevalence: ~12% of the general
population. A5 SEPARATION ANXIETY DISORDER
●​ More common in women than men
(slightly).
●​ Onset typically in adolescence (around ●​ Separation Anxiety Disorder (SAD) is
13 years old). characterized by excessive fear or anxiety
●​ Higher risk for developing depression about being separated from attachment
and substance use disorders. figures, such as parents, caregivers, or
loved ones. While it is more common in
children, it can also persist into
CAUSES
adulthood. The fear is disproportionate to
the actual threat and significantly
1.​ Overprotective or critical parenting. impairs daily life.
2.​ Cultural influences (e.g., collectivist
cultures may reinforce fear of social
DIAGNOSTIC CRITERIA FOR
scrutiny).
SEPARATION ANXIETY DISORDER
3.​ Genetic predisposition (heritability
~30-40%).
4.​ Dysfunction in the amygdala, leading to
A. Developmentally inappropriate and
an exaggerated fear response.
excessive fear and anxiety concerning
5.​ Imbalance in serotonin and dopamine.
separation from those to whom the
individual is attached, as evidence by at
TREATMENT least of the following:

1. Excessive distress when anticipating or

●​ Cognitive-Behavioral Therapy (CBT)
experiencing separation from attachment
-​ Cognitive restructuring:
figures.
Identifying and changing
2. Persistent worry about losing attachment
negative thought patterns.
figures (e.g., due to illness, accidents, or
-​ Exposure therapy: Gradual
death).
exposure to feared social
3. Fear of an event leading to separation (e.g.,
situations.
getting lost, being kidnapped).
-​ Social skills training: Teaching
4. Refusal to go out (e.g., school, work, travel)
effective communication and
due to fear of separation.
assertiveness.
5. Excessive fear of being alone or away from
attachment figures.
●​ Medications
6. Reluctance or refusal to sleep away from
home or without the attachment figure.

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 COMPETENCY APPRAISAL I
BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

irrational thoughts about

7. Frequent nightmares about separation.
separation.
8. Physical symptoms (e.g., headaches,
➢​ Exposure therapy: Gradual,
stomachaches, nausea) when separation is
controlled exposure to separation
anticipated or occurs.
scenarios to reduce anxiety.
B. . The fear, anxiety, or avoidance is
●​ Family Therapy
persistent, lasting at least 4 weeks in
➢​ Educates parents on how to
children and adolescents and typically 6
support their child’s
months or more in adults.
independence.
➢​ Helps family members reduce
C. The disturbance causes clinically
accommodating behaviors that
significant distress or impairment in social,
reinforce anxiety.
academic, occupational, or other important
areas of functioning.
●​ Medications (for severe cases)
➢​ Selective serotonin reuptake
inhibitors (SSRIs) (e.g., fluoxetine,
STATISTICS
sertraline) to reduce anxiety.
➢​ Benzodiazepines (short-term use
●​ Children: Affects ~4% of children, making in extreme cases).
it one of the most common anxiety
disorders in childhood. A6 SELECTIVE MUTISM
●​ Adolescents: Prevalence is ~1.6%.
●​ Adults: Around 0.9%–1.9% experience
separation anxiety. ●​ Selective Mutism is a rare anxiety
●​ Onset: Typically starts in childhood, but disorder characterized by a child's
30-40% of cases persist into adulthood. consistent failure to speak in specific
●​ More common in females than males. social situations (e.g., school, public
settings) despite being able to speak
normally in comfortable environments
CAUSES
(e.g., at home with family). The condition
is not due to a speech or language
1.​ Early childhood trauma (e.g., parental disorder but is rooted in severe social
divorce, loss of a loved one, moving to a anxiety.
new location).
2.​ Modeling: Parents with anxiety disorders
DIAGNOSTIC CRITERIA FOR
may unintentionally reinforce fears.
SELECTIVE MUTISM
3.​ Genetic predisposition (family history of
anxiety disorders).
4.​ Imbalance in serotonin and
A. Consistent failure to speak in specific
norepinephrine, affecting emotional
social situations in which there is an
regulation.
expectation for speaking (e.g., at school)
despite speaking in other situations.
TREATMENTS
B. The disturbance interferes with
educational or occupational achievement
●​ Cognitive-Behavioral Therapy (CBT)
or with social communication.
➢​ Cognitive restructuring:
Teaching individuals to challenge

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 COMPETENCY APPRAISAL I
BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

C. The duration of the disturbance is at TREATMENT

least 1 month (not limited to the 1st month
of school).
●​ Behavioral Therapy (First-Line
Treatment)
D. The failure to speak is not attributable to
➢​ Gradual Exposure Therapy:
a lack of knowledge of, or comfort with, the
Encouraging small steps toward
spoken language required in the social
speaking in feared settings.
situation.
●​ Parent and Teacher Training
E. The disturbance is not better explained
➢​ Educating caregivers on how to
by a communication disorder (e.g.,
reduce pressure to speak and
childhood-onset fluency disorder) and does
reinforce social engagement.
not occur exclusively during the course of
autism spectrum disorder, schizophrenia, or
●​ Medications (for severe cases)
another psychotic disorder.
➢​ Selective Serotonin Reuptake
Inhibitors (SSRIs) (e.g., fluoxetine)
can reduce anxiety in extreme
STATISTIC
cases.

●​ Prevalence: Affects ~0.3–1% of children,

B TRAUMA AND STRESSOR - RELATED
with higher rates in young children.
DISORDERS
●​ Gender Differences: More common in
girls than boys.
●​ Onset: Typically starts between ages 3–6, ●​ The DSM-5 groups trauma and
often first noticed when a child enters stressor-related disorders together, as
school. they all develop after stressful or
●​ Course: Without treatment, symptoms
traumatic events. These include
can persist into adolescence and
adulthood, leading to severe social and attachment disorders in children due to
academic impairments. inadequate caregiving, adjustment
disorders with persistent anxiety or
CAUSES depression after stress, and trauma
reactions like PTSD and acute stress
disorder. Researchers found these
1.​ Overprotective parenting: Parents who
disorders differ from anxiety disorders
shield children from discomfort may
reinforce avoidance behavior. because they share a clear triggering
2.​ Early traumatic experiences (e.g., harsh event and involve a wider range of
criticism, bullying, or forced speech in emotions, including rage, horror, guilt,
stressful situations). and shame, not just fear and anxiety.
3.​ Bilingualism: In some cases, selective
mutism occurs in children exposed to
multiple languages, though this alone is B1 POSTTRAUMATIC STRESS DISORDER
not a cause.
4.​ Genetic predisposition (family history of ●​ Historical Context of PTSD
anxiety disorders). - Although PTSD was officially recognized
5.​ Overactive amygdala, leading to in DSM-III (1980), descriptions of
heightened fear responses. trauma-related distress date back

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

centuries. For example, in 1666, British

- Efforts to avoid places, people,
diarist Samuel Pepys documented his
conversations, or activities that trigger
psychological distress after witnessing
memories of the trauma.
the Great Fire of London. Months later,
- Inability or unwillingness to recall key
he reported nightmares, severe anxiety,
details of the event.
and emotional numbness—symptoms
now recognized as PTSD. His guilt over
3.​ Negative Changes in Mood and
surviving while others perished is also a
Cognition
well-documented response in PTSD
- Emotional numbing, detachment
cases.
from others, and difficulty experiencing
positive emotions.
●​ Posttraumatic stress disorder (PTSD)
- Persistent negative beliefs about
- is a psychiatric disorder that may occur
oneself or the world (e.g., "I am unsafe"
in people who have experienced or
or "I can't trust anyone").
witnessed a traumatic event, series of
- Guilt or shame, especially in cases
events or set of circumstances. An
where the individuals survived while
individual may experience this as
others did not.
emotionally or physically harmful or
life-threatening and may affect mental,
4.​ Arousal and Reactivity
physical, social, and/or spiritual
- Hypervigilance, exaggerated startle
well-being.
response, and trouble sleeping.
- Irritability, angry outbursts, reckless or
●​ Examples:
self-destructive behavior (added in
- include natural disasters, serious
DSM-5).
accidents, terrorist acts, war/combat,
rape/sexual assault, historical trauma,
5.​ New Features in DSM-5
intimate partner violence and bullying.
- The reckless or self-destructive
-​ Wars in Iraq and Afghanistan
behavior criterion was introduced as
-​ Terrorist Attack on September 11,
part of increased arousal symptoms.
2001 ( \World Trade Center)
- A dissociative subtype was added,
-​ Hurricane Sandy in 2012 (USA)
describing individuals with PTSD who
-​ Typhoon Yolanda in 2013 (PHI)
experience dissociation (detachment
from reality) instead of hyperarousal.
SYMPTOMS These individuals often report feelings
of unreality, emotional numbness, or
depersonalization.
●​ After the trauma, individuals may
experience a range of symptoms,
grouped into four main categories: B2 THE JONESES CASE STUDY (ONE
VICTIM, MANY TRAUMAS)
1.​ Reexperiencing the Trauma
- Intrusive and distressing memories,
nightmares, and flashbacks where
Mrs. Betty Jones and her four children arrived
individuals feel as if they are reliving
at a farm to visit a friend. (Mr. Jones was at
the event.
work.) Jeff, the oldest child, was 8 years old.
- Sudden emotional reactions
Marcie, Cathy, and Susan were 6, 4, and 2
triggered by reminders of the trauma.
years of age. Mrs. Jones parked the car in the
driveway, and they all started across the yard
2.​ Avoidance
to the front door. Suddenly Jeff heard

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

Note: Jeff and Marcie exhibited classic trauma

growling somewhere near the house. Before
responses after the incident. Jeff experienced
he could warn the others, a large German
survivor’s guilt, believing he should have
shepherd charged and leapt at Marcie, the 6
protected Marcie. Both regressed
year old, knocking her to the ground and
developmentally, with bedwetting,
tearing viciously at her face. The family, too
nightmares, and separation anxiety. Marcie
stunned to move, watched the attack
developed medical fears due to her hospital
helplessly. After what seemed like an eternity,
experience and refused routine activities like
Jeff lunged at the dog and it moved away. The
bathing or being tucked into bed. Jeff resumed
owner of the dog, in a state of panic, ran to a
finger-sucking, a behavior he had outgrown.
nearby house to get help. Mrs. Jones
Their younger siblings, Cathy and Susan, also
immediately put pressure on Marcie’s facial
showed trauma-related behaviors—Cathy
wounds in an attempt to stop the bleeding.
displayed fear and avoidance but denied issues,
The owner had neglected to retrieve the dog,
while 2-year-old Susan repeatedly stated,
and it stood a short distance away, growling
“Doggy bit sister,” indicating distress despite
and barking at the frightened family.
her young age. These symptoms align with
Eventually, the dog was restrained and Marcie
common childhood trauma responses.
was rushed to the hospital. Marcie, who was
hysterical, had to be restrained on a padded
Note: PTSD cannot be diagnosed until at least
board so that emergency room physicians
one month after a traumatic event, as many
could stitch her wounds.
people experience temporary stress reactions
that subside. In delayed-onset PTSD, symptoms
-​ This case is unusual because not only may not appear until six months or even years
did Marcie develop PTSD, but so did her later, though the reason for this delay is unclear.
8-year-old brother. In addition, Cathy, 4, The DSM-IV introduced acute stress disorder
and Susan, 2, although quite young, (ASD) to describe severe reactions within the
showed symptoms of the disorder, as did first month, distinguishing it from PTSD. Studies
their mother (see Table 5.7) show that about 50% of individuals with ASD
develop PTSD, but many PTSD cases occur
without prior ASD diagnosis. ASD was added
partly to ensure insurance coverage for early
treatment, but early severe reactions do not
always predict long-term PTSD.

STATISTICS

●​ Lifetime Prevalence: Estimates range

from 6% to 7% of people experiencing
PTSD at some point in their lives.
(Lifetime prevalence refers to the
percentage of people who have ever had
PTSD at any time in their life).
●​ Gender Ratio: Women are about twice
as likely as men to develop PTSD (10-12%
vs. 5-6%).
●​ Age of Onset: PTSD can develop at any
age, but the highest risk is in early
adulthood (18-30 years) due to increased
exposure to trauma.

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●​ Childhood PTSD: Around 5% of

-​ Childhood abuse or neglect
adolescents (ages 13-18) experience PTSD,
-​ Medical trauma (severe illness,
with girls (8%) more affected than boys
painful procedures)
(2.3%).
-​ Terrorist attacks or witnessing
●​ Older Adults: PTSD can resurface or
violence
worse later in life, especially among war
veterans and trauma survivors.
2. Biological Factors
●​ Chronicity: Without treatment, PTSD can
become chronic and persist for years ➢​ Genetic predisposition
-​ Family history of anxiety or
NOTE: PTSD tends to be chronic and is a
mood disorders increases PTSD
strong predictor of suicidal attempts,
risk.
independent of other issues like alcohol
-​ Twin studies show higher PTSD
abuse. However, not everyone reacts
concordance in identical twins.
the same way to trauma. While some
○​
endure extreme experiences and remain
➢​ Neurobiological responses
psychologically healthy, others develop
-​ Overactive amygdala (fear
PTSD from relatively mild stressors.
processing) intensifies reactions
Differences in resilience, coping skills,
to stress.
trauma exposure, early adversity,
-​ Underactive prefrontal cortex
ongoing stress, and even mild
(emotion regulation) makes it
traumatic brain injuries all play a role in
harder to control fear.
how PTSD develops. Understanding why
-​ HPA axis dysregulation (stress
some are more vulnerable requires
hormone imbalance) prolongs
exploring its underlying causes.
stress responses.
➢​ Serotonin transporter gene
CAUSES (5-HTTLPR) variations
-​ Certain genetic variants
increase vulnerability to PTSD,
●​ PTSD is unique because its cause is especially in response to
known: a traumatic event. However, trauma.
whether someone develops PTSD
depends on a combination of factors, 3. Psychological Factors
including trauma exposure, biological
predispositions, psychological ➢​ Pre-existing mental health
vulnerabilities, and social influences. conditions (e.g., anxiety, depression,
personality disorders)
1. Exposure to Trauma (Essential Factor) ➢​ Tendency toward high anxiety or
neuroticism
➢​ Direct personal experience with ➢​ Negative coping mechanisms (e.g.,
life-threatening or highly distressing avoidance, substance use)
events ➢​ Sense of lack of control over life
-​ Combat exposure (e.g., war events
veterans) ➢​ Dissociation during trauma (feeling
-​ Physical or sexual assault detached from reality)
-​ Natural disasters (earthquakes,
hurricanes, fires) 4. Social Environmental Factors
-​ Severe accidents (car crashes,
workplace injuries)

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➢​ Early childhood adversity (abuse,

neglect, parental instability)
➢​ Lack of social support after trauma
➢​ Repeated or prolonged trauma
exposure (e.g., domestic violence, war
zones)
➢​ Cultural and societal factors (e.g.,
stigma against seeking help)

5. Severity and Proximity of Trauma

➢​ Direct exposure vs. indirect exposure

-​ The closer a person is to the
trauma, the higher the risk
➢​ Intensity and duration of trauma
-​ More severe, prolonged trauma
(e.g., torture, captivity) leads to
higher PTSD rates
➢​ Type of trauma
-​ Assaultive violence (rape,
torture, physical abuse) is more
likely to cause PTSD than
natural disasters or accidents.

●​ PTSD and panic disorder share

similarities in their alarm reaction, but in
PTSD, the initial fear response is to a real
threat. If the trauma is severe enough,
individuals may develop a conditioned
alarm reaction, where certain stimuli
trigger intense fear or flashbacks. This
learned response can lead to ongoing
anxiety about experiencing
uncontrollable emotional episodes.
DIAGNOSTIC CRITERIA FOR
Whether someone develops PTSD
POSTTRAUMATIC STRESS DISORDER
depends on individual vulnerabilities,
including biological and psychological
factors.
A. Exposure to actual or threatened death,
serious injury, or sexual violence in one (or
more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as they
occurred to others.
3. Learning that the event(s) occurred to a
close relative or close friend. In cases of actual
or threatened death of a family member or
friend, the event(s) must have been violent or

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

accidental. 1. Avoidance of or efforts to avoid distressing

4. Experiencing repeated or extreme exposure memories, thoughts, feelings, or
to aversive details of the traumatic event(s) conversations about or closely associated with
(e.g., first responders collecting human the traumatic event(s).
remains; police officers repeatedly exposed to 2. Avoidance of or efforts to avoid external
details of child abuse). reminders (people, places, conversations,
activities, objects, situations) that arouse
Note: Criterion A4 does not apply to exposure distressing memories, thoughts, or feelings
through electronic media, television, movies, about or closely associated with the traumatic
or pictures, unless this exposure is work event(s).
related.
D. Negative alterations in cognitions and
B. Presence of one (or more) of the mood associated with the traumatic
following intrusion symptoms associated event(s), beginning or worsening after the
with the traumatic event(s), beginning after traumatic event(s) occurred, as evidenced
the traumatic event(s) occurred: by two (or more) of the following:

1. Recurrent, involuntary and intrusive 1. Inability to remember an important aspect

distressing memories of the traumatic of the traumatic event(s) (typically due to
event(s). Note: In young children, repetitive dissociative amnesia and not to other factors
play may occur in which themes or aspects of such as head injury, alcohol, or drugs).
the traumatic event(s) are expressed. 2. Persistent and exaggerated negative beliefs
2. Recurrent distressing dreams in which the or expectations about oneself, others, or the
content and/or affect of the dream are related world (e.g., “I am bad,” “no one can be trusted,”
to the traumatic event(s). Note: In children, “the world is completely dangerous,” “My
there may be frightening dreams without whole nervous system is permanently
recognizable content. ruined”).
3. Dissociative reactions (e.g., flashbacks) in 3. Persistent distorted cognitions about the
which the individual feels or acts as if the cause or consequences of the traumatic
traumatic event(s) were recurring. (Such event(s) that lead the individual to blame
reactions occur on a continuum, with the himself/herself or others.
most extreme expression being a complete 4. Persistent negative emotional state (e.g.,
loss of awareness of present surroundings.) fear, horror, anger, guilt, or shame).
Note: In young children, trauma specific 5. Markedly diminished interest or
reenactment may occur in play. participation in significant activities.
4. Intense or prolonged psychological distress 6. Feelings of detachment or estrangement
at exposure to internal or external cues that from others.
symbolize or resemble an aspect of the 7. Persistent inability to experience positive
traumatic event(s). emotions (e.g., inability to experience
5. Marked physiological reactions to internal happiness, satisfaction, or loving feelings).
or external cues that symbolize or resemble
an aspect of the traumatic event(s). E. Marked alterations in arousal and
reactivity associated with the traumatic
C. Persistent avoidance of stimuli event(s), beginning or worsening after the
associated with the traumatic event(s), traumatic event(s) occurred, as evidenced
beginning after the traumatic event(s) by two (or more) of the following:
occurred, as evidenced by one or both of
the following: 1. Irritable behavior and angry outbursts (with
little or no provocation) typically expressed as

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

confront their trauma, process their

verbal or physical aggression toward people or
emotions, and develop coping strategies
objects.
to mitigate the disorder’s effects.
2. Reckless or self-destructive behavior.
●​ Psychoanalytic Therapy
3. Hypervigilance.
-​
4. Exaggerated startle response.
➢​ Catharsis - where emotional trauma is
5. Problems with concentration.
relieved to reduce suffering. Since
recreating traumatic events is
F. Sleep disturbance (e.g., difficulty falling
challenging, therapists use imaginal
or staying asleep or restless sleep).Duration
exposure, systematically working
of the disturbance (Criteria B, C, D and E) is
through trauma-related emotions.
more than one month.
➢​ Cognitive Behavioral Therapy (CBT) –
Helps patients identify and change
G. The disturbance causes clinically
negative thought patterns related to
significant distress or impairment in social,
trauma.
occupational, or other important areas of
➢​ Prolonged Exposure Therapy (PE) –
functioning.
Involves repeated, controlled exposure to
trauma-related memories to reduce
H. The disturbance is not attributable to the
avoidance and fear.
physiological effects of a substance (e.g.,
➢​ Cognitive Processing Therapy (CPT) –
medication, alcohol) or another medical
Focuses on changing unhelpful beliefs
condition.
about the trauma.
➢​ Eye Movement Desensitization and
NOTE:
Reprocessing (EMDR) – Uses guided eye
movements while recalling trauma to
Specify if With delayed expression:
reduce emotional distress.
-​ If the full diagnostic criteria are not
➢​ Trauma-Focused Therapy – Integrates
met until at least 6 months after the
different therapeutic approaches to
event (although it is understood that
address trauma in children and adults.
onset and expression of some
symptoms may be immediate).
NOTE: Recent research suggests that
-​
exposure therapy may be more effective
Specify whether With Dissociative
when strategically timed with sleep.
Symptoms:
Studies indicate that taking a nap after
-​ The individual’s symptoms meet the
exposure treatment enhances extinction
criteria for posttraumatic stress
learning during slow-wave sleep and
disorder, and in addition, in response
improves sleep quality, which helps
to the stressor, the individual
reduce anxiety.
experiences persistent or recurrent
symptoms of either depersonalization
●​ Medication
or derealization.
-​
➢​ Selective Serotonin Reuptake Inhibitors
(SSRIs) – Such as sertraline (Zoloft) and
paroxetine (Paxil), commonly prescribed
for PTSD.
TREATMENTS ➢​ Serotonin-Norepinephrine Reuptake
Inhibitors (SNRIs) – Like venlafaxine
●​ From a psychological perspective, most (Effexor), used to treat PTSD symptoms.
clinicians agree that PTSD victims should ➢​ Prazosin – Helps reduce nightmares and
sleep disturbances.

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 COMPETENCY APPRAISAL I
BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

➢​ D-Cycloserine (DCS) is a medication that and heightened emotional responses

has been studied as an adjunct to such as fearfulness and intense
exposure therapy for PTSD and anxiety sadness.
disorders.
➢​ Other Medications – Mood stabilizers or 2. In disinhibited social engagement
antipsychotics may be used in severe disorder (DSED), children who
cases. experience early neglect or harsh
punishment develop a pattern of overly
familiar behavior with strangers. They
B3 ADJUSTMENT DISORDERS
show no hesitation in approaching
unfamiliar adults and may even go with
●​ involve anxious or depressive reactions them without checking with a caregiver.
to life stress that are milder than acute Previously grouped with reactive
stress disorder or PTSD but still impair attachment disorder (RAD) in DSM-IV,
daily functioning, such as work, school, or DSED is now a separate diagnosis in
relationships. In adolescents, stress may DSM-5 due to its distinct behavioral
lead to conduct problems. While the patterns.
stressors are not classified as traumatic,
individuals struggle to cope, often
C OBSESSIVE-COMPULSIVE AND
requiring intervention. If symptoms last
RELATED DISORDERS
more than six months, the condition is
considered chronic. Historically,
adjustment disorder has been used as a ●​ Obsessive-Compulsive Disorder (OCD)
broad diagnosis for stress-related anxiety ●​ Body Dysmorphic Disorder (BDD)
or depression that does not fit other ●​ Hoarding Disorder
clinical categories, leading to limited ●​ Trichotillomania (hair pulling) Disorder
research on the condition.
●​ Excoriation (skin picking) Disorder

B4 ATTACHMENT DISORDERS
C1 OBSESSIVE-COMPULSIVE DISORDER

●​ are developmentally inappropriate

behaviors in children under five years old ●​ OCD is characterized by the presence of
who struggle to form normal bonds with obsessions and/or compulsions.
caregivers due to inadequate or abusive ●​ Obsessions are intrusive and mostly
caregiving. Causes include neglect, nonsensical thoughts, images, or urges
frequent caregiver changes (e.g., multiple that the individual tries to resist or
foster placements), and failure to meet
eliminate (it could be about anything).
the child’s emotional or basic needs.
These disorders are seen as pathological ●​ Compulsions are the thoughts or actions
responses to early extreme stress. In used to suppress the obsessions and
DSM-5, attachment disorders are provide relief. These are the repetitive
classified into two types: behaviors or mental acts that an
individual feels driven to perform in
1. Reactive attachment disorder (RAD), response to an obsession or according to
a child rarely seeks or responds to
rules that must be applied rigidly.
caregivers for protection, support, or
nurturance. They exhibit emotional ●​ Compulsions can be either behavioral
withdrawal, limited positive emotions, (hand-washing or checking) or mental
(thinking about certain words in a

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

specific order, counting, praying, and so to suppress a suggested thought or

on). image. Individuals with OCD fight this
battle all day, every day, sometimes for
most of their lives, and they usually fail
OBSESSIVE-COMPULSIVE DISORDER
AND ANXIETY DISORDERS miserably.

2.​ Richard, a 19-year-old college freshman

●​ OCD is the devastating culmination of
majoring in philosophy, withdrew from
the anxiety disorders.
school because of incapacitating
●​ It is not uncommon for someone with
ritualistic behavior. He abandoned
OCD to experience severe generalized
personal hygiene because the
anxiety, recurrent panic attacks,
compulsive rituals that he had to carry
debilitating avoidance, and major
out during washing or cleaning were so
depression, all occurring simultaneously
time consuming that he could do
with obsessive-compulsive symptoms.
nothing else. Almost continual
With OCD, establishing even a foothold
showering gave way to no showering. He
of control and predictability over the
stopped cutting and washing his hair
dangerous events in life seems so
and beard, brushing his teeth, and
utterly hopeless that victims resort to
changing his clothes. He left his room
magic and rituals (because of these
infrequently and, to avoid rituals
unwanted thoughts, images or urges,
associated with the toilet, defecated on
they tend to conduct these repetitive
paper towels, urinated in paper cups, and
behavioral or mental acts to gain a sense
stored the waste in the closet. He ate
of control).
only late at night when his family was
●​ BUT HOW can we differentiate
asleep. To be able to eat, he had to exhale
someone with OCD and someone with
completely, making a lot of hissing
other anxiety disorders who are both
noises, coughs, and hacks, and then fill
experiencing Anxiety? In other anxiety
his mouth with as much food as he could
disorders, the danger is usually in an
while no air was in his lungs. He would
external object or situation, or at least in
eat only a mixture of peanut butter,
the memory of one. In OCD, the
sugar, cocoa, milk, and mayonnaise. All
dangerous event is a thought, image, or
other foods he considered contaminants.
impulse that the client attempts to avoid
When he walked, he took small steps on
as completely as someone with a snake
his toes while continually looking back,
phobia avoids snakes.
checking and rechecking. Occasionally,
he ran quickly in place. He withdrew his
EXAMPLE left arm completely from his shirt sleeve
as if he were crippled and his shirt was a
1.​ For example, has anyone ever told you sling. [(Like everyone with OCD, Richard
not to think of pink elephants? 🐘 If you experienced intrusive and persistent
thoughts and impulses; in his case,
really concentrate on not thinking of pink
elephants, using every mental means they were about sex, aggression, and
possible, you will realize how difficult it is religion. His various behaviors were

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

efforts to suppress sexual and 4. Walking and Movement

aggressive thoughts or to ward off the Rituals: His unusual walking patterns,
disastrous consequences he thought such as taking small steps on his toes,
would ensue if he did not perform his continually looking back, and running
rituals. Richard performed most of the quickly in place, are likely compulsions to
repetitive behaviors and mental acts ward off perceived dangers or anxieties.
mentioned in the DSM-5 criteria. The
important thing is that they are believed
DIAGNOSTIC CRITERIA FOR
to reduce stress or prevent a dreaded OBSESSIVE-COMPULSIVE DISORDER
event. Compulsions are often “magical”
in that they may bear no logical relation
to the obsession)]. A. Presence of obsessions, compulsions or
both: Obsessions are defined by 1 and 2:

SAMPLE CASE INTERPRETATION 1. Recurrent and persistent thoughts, urges, or

(BREAKDOWN OF OBSESSIONS AND images that are experienced, at some time
COMPULSIONS)
during the disturbance, as intrusive and
inappropriate and that in most individuals
●​ Richard’s Obsessions: sex, aggression cause marked anxiety or distress.
religion 2. The individual attempts to ignore or
●​ Richard’s Compulsions (Behavioral): suppress such thoughts, impulses, or images,
1. Initial Excessive Cleaning: or to neutralize them with some other
Richard started with excessive thought or action.
showering, which was likely a
compulsion to clean himself obsessively, Compulsions are defined by 1 and 2:
possibly due to fears of contamination or 1. Repetitive behaviors (e.g., handwashing,
moral impurity. ordering, checking) or mental acts (e.g.,
2. Avoidance of Cleaning: praying, counting, repeating words silently)
However, this excessive cleaning became that the individual feels driven to perform in
so time-consuming that it interfered with response to an obsession, or according to
his daily life. In an attempt to escape this rules that must be applied rigidly.
anxiety-provoking behavior, Richard 2. The behaviors or mental acts are aimed at
developed a new compulsion: avoiding preventing or reducing distress or preventing
cleaning altogether. This might seem some dreaded event or situation; however,
counterintuitive, but it's an example of these behaviors or mental acts either are not
how OCD can lead to contradictory connected in a realistic way with what they
behaviors. are designed to neutralize or prevent or are
3. Eating Rituals: Richard's eating clearly excessive .
habits, such as exhaling completely,
making hissing noises, and only eating a B. The obsessions or compulsions are
specific mixture of foods, are time-consuming (e.g., take more than 1
compulsions aimed at reducing anxiety hour per day), or cause clinically significant
related to contamination or other distress or impairment in social,
occupational or other important areas of
obsessive fears.

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other thoughts or actions, such as

functioning.
performing rituals. Richard's compulsions
C. The disturbance is not due to the direct include repetitive behaviors like excessive
physiological effects of a substance (e.g., a showering, eating rituals, and checking
drug of abuse, a medication) or another behaviors, which he feels driven to
medical condition. perform in response to his obsessions.
These behaviors are aimed at reducing
D. The disturbance is not better explained
distress or preventing some dreaded
by the symptoms of another mental
disorder (e.g., excessive worries, as in event, even though they are excessive
generalized anxiety disorder, or and not connected in a realistic way to
preoccupation with appearance, as in body what they are designed to neutralize or
dysmorphic disorder). prevent.
●​ Secondly, Richard's obsessions and
Specify if:
compulsions are time-consuming, taking
up most of his day, and cause clinically
With good or fair insight: the individual
significant distress and impairment in
recognizes that obsessive compulsive
social, occupational, and other areas of
disorder beliefs are definitely or probably not
functioning (Criteria B). He has
true or that they may or may not be true.
withdrawn from school, abandoned
With poor insight: The individual thinks
personal hygiene, and isolated himself
obsessive-compulsive disorder beliefs are
from his family and friends.
probably true.
●​ Thirdly, Richard's disturbance is not due
With absent insight/delusional: the person is
to the direct physiological effects of a
completely convinced that
substance or another medical condition
obsessive-compulsive disorder beliefs are
(Criteria C).
true.
●​ Finally, Richard's disturbance is not
Specify if: Tic-related: The individual has a
better explained by the symptoms of
current or past history of a tic disorder.
another mental disorder, such as
generalized anxiety disorder or body
dysmorphic disorder (Criteria D).
SAMPLE CASE INTERPRETATION
●​ Richard's symptoms are classic examples
(BASED ON THE DIAGNOSTIC
CRITERIA FOR OCD) of OCD, and his case meets all the
diagnostic criteria for the disorder.

●​ Richard's case meets all the diagnostic

criteria for Obsessive-Compulsive TIC DISORDER AND OBSESSIVE
Disorder (OCD). Firstly, Richard exhibits COMPULSIVE DISORDER
both obsessions and compulsions
(Criteria A). His intrusive and persistent ●​ It is also common for tic disorders,
thoughts about sex, aggression, and characterized by involuntary movement
religion, which cause him marked anxiety (sudden jerking of limbs, for example), to
and distress, are classic examples of co-occur in patients with OCD
obsessions. He attempts to suppress (particularly children) or in their families.
these thoughts or neutralize them with Approximately 10% to 40% of children

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 COMPETENCY APPRAISAL I
BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

and adolescents with OCD also have had ●​ The age of onset peaks earlier in males
tic disorder at some point (Leckman et (13 to 15) than in females (20 to 24).
al., 2010). The obsessions in tic-related ●​ Once OCD develops, it tends to become
OCD are almost always related to chronic.
symmetry.

CAUSES

1.​ Generalized Biological and

Psychological Vulnerabilities:
-​ Genetic predisposition
-​ Brain circuitry abnormalities
-​ Generalized anxiety sensitivity

2.​ Specific Psychological Vulnerability:

-​ Thought-Action Fusion (TAF):
believing that having intrusive
thoughts means they're
responsible for the terrible things
they're thinking.
-​ Attitudes of excessive
responsibility.
-​ Believing some thoughts are
STATISTICS unacceptable and must be
suppressed.
3.​ Environmental and Learning Factors:
●​ Estimates of the lifetime prevalence of
-​ Early experiences that teach
OCD range from 1.6% to 2.3% and in a
individuals that some thoughts
given 1-year period the prevalence is 1%.
are dangerous and unacceptable
(What is lifetime prevalence? Lifetime
-​ Misinformation and learning
prevalence is the percentage of people
processes that contribute to TAF
who have ever had a specific condition or
and excessive responsibility
disease at any point in their life).
attitudes
●​ OCD has a ratio of female to male that is
-​ Cultural and religious beliefs that
nearly 1:1.
emphasize the importance of
●​ Although there is some evidence in
controlling thoughts and
children that there are more males than
behaviors
females this seems to be because boys
tend to develop OCD earlier.
●​ By mid-adolescence, the sex ratio is TREATMENT
approximately equal.
●​ Age of onset ranges from childhood ●​ The most effective drugs seem to be
through the 30s, with a median age of those that specifically inhibit the
onset of 19 reuptake of serotonin, such as

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

clomipramine or the SSRIs, which benefit something/ obsession/fixation) with one

up to 60% of patients with OCD, with no or more perceived defects or flaws in
particular advantage to one drug over physical appearance that are not
another. Relapse often occurs when the observable or appear only slight to
drug is discontinued, however. others, and by repetitive behaviors
●​ The most effective treatment approach is (e.g., mirror checking, excessive
a psychological treatment called grooming, skin picking, or reassurance
exposure and ritual prevention (ERP), a seeking) or mental acts (e.g., comparing
process whereby the rituals are actively one's appearance with that of other
prevented and the patient is people) in response to the appearance
systematically and gradually exposed to concerns.
the feared thoughts or situations. ●​ The disorder has been referred to as
“imagined ugliness.’’
●​ The appearance preoccupations are not
better explained by concerns with body
fat or weight in an individual with an
eating disorder.
●​ Muscle dysmorphia is a form of body
dysmorphic disorder that is characterized
by the belief that one's body build is too
small or is insufficiently muscular.
●​ Many people with this disorder become
fixated on mirrors. They often check their
presumed ugly features to see whether
any change has taken place. Others avoid
mirrors to an almost phobic extent. Quite
understandably, suicidal ideation, suicide
attempts, and suicide itself are typical
consequences of this disorder.

EXAMPLE

1.​ In his mid-20s, Jim was diagnosed with

suspected social anxiety disorder; he was
referred to our clinic by another
professional. Jim had just finished
rabbinical school and had been offered a
position at a synagogue in a nearby city.
C2 BODY DYSMORPHIC DISORDER He found himself unable to accept,
however, because of marked social
●​ It is characterized by preoccupation difficulties. Lately he had given up
(being preoccupied or engrossed with leaving his small apartment for fear of
running into people he knew and being

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forced to stop and interact with them.

excessive grooming, skin picking,
Jim was a good-looking young man of reassurance seeking) or mental acts (e.g.,
about average height, with dark hair comparing his or her appearance with that
and eyes. Although he was somewhat of others) in response to the appearance
depressed, a mental status exam and a concerns.
brief interview focusing on current
functioning and past history did not C. The preoccupation causes clinically
significant distress or impairment in social,
reveal any remarkable problems. There
occupational, or other important areas of
was no sign of a psychotic process (he functioning.
was not out of touch with reality). We
then focused on Jim’s social difficulties. D. The appearance preoccupation is not
We expected the usual kinds of anxiety better explained by concerns with body fat
about interacting with people or “doing or weight in an individual whose symptoms
meet diagnostic criteria for an eating
something” (performing) in front of
disorder.
them. But this was not Jim’s concern.
Rather, he was convinced that everyone, Specify if:
even his good friends, was staring at a
part of his body that he found grotesque. With good or fair insight: The individual
He reported that strangers would never recognizes that the body dysmorphic disorder
mention his deformity and his friends felt beliefs are definitely or probably not true or
too sorry for him to mention it. Jim that they may or may not be true.
thought his head was square! Like the With poor insight: The individual thinks that
Beast in Beauty and the Beast who could the body dysmorphic disorder beliefs are
not imagine people reacting to him with probably true.
anything less than revulsion, Jim could With absent insight/delusional beliefs: the
not imagine people getting past his individual is completely convinced that the
square head. To hide his condition as well body dysmorphic disorder beliefs are true.
as he could, Jim wore soft floppy hats With muscle dysmorphia: The individual is
and was most comfortable in winter, preoccupied with the idea that his or her
when he could all but completely cover body build is too small or insufficiently
his head with a large stocking cap. To us, muscular. This specifier is used even if the
Jim looked normal. individual is preoccupied with other body
areas, which is often the case.
DIAGNOSTIC CRITERIA FOR BODY
DYSMORPHIC DISORDER
SAMPLE CASE INTERPRETATION
(BASED ON THE DIAGNOSTIC
A. Preoccupation with one or more defects CRITERIA OF BDD)
or flaws in physical appearance that are not
observable or appear slight to others. ●​ Firstly, Jim had a preoccupation with one
or more defects or flaws in his physical
B. At some point during the course of the
disorder, the individual has performed appearance (Criteria A). Specifically, he
repetitive behaviors (e.g., mirror checking, was convinced that his head was square,

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which was a perceived flaw that was not

observable to others.

●​ This preoccupation led Jim to perform

repetitive behaviors in response to his
appearance concerns (Criteria B). For
example, he wore soft floppy hats and
large stocking caps to hide his
"deformity". He also avoided social
interactions and stayed at home, which
could be seen as a mental act aimed at
avoiding situations that might trigger his
appearance concerns.

●​ Jim's preoccupation with his appearance

caused significant distress and
impairment in his social and
occupational life (Criteria C). He had just
finished rabbinical school and was
offered a job, but he couldn't accept it
due to his social anxiety and fear of being
judged by others. He also avoided leaving
STATISTICS
his apartment and interacting with
people he knew, which further
exacerbated his social isolation. ●​ Age of onset ranges from early
adolescence through the 20s, peaking at
●​ Finally, Jim's appearance preoccupation the age of 16–17.
was not better explained by concerns ●​ BDD is seen equally in men and women.
with body fat or weight in an individual ●​ The prevalence of BDD is hard to
whose symptoms meet diagnostic estimate because by its very nature it
criteria for an eating disorder (Criteria D). tends to be kept secret.
His concerns were specifically focused on
the shape of his head, rather than his BDD AND PLASTIC SURGERY
weight or body fat.

●​ In mental health clinics, the disorder is

●​ Overall, Jim's symptoms and behaviors
also uncommon because most people
meet the diagnostic criteria for Body
with BDD seek other types of health
Dysmorphic Disorder (BDD).
professionals, such as plastic surgeons
and dermatologists.
To give you a better idea of the types of concerns
●​ Patients with BDD believe they are
people with BDD present to health
physically deformed in some way and go
professionals, the locations of imagined defects
to medical doctors to attempt to correct
in 200 patients are shown in Table.
their deficits.

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

●​ Because the concerns of people with medical condition that coexists

BDD involve mostly the face or head, it is alongside a primary diagnosis and
not surprising that the disorder is big affects your health).
business for the plastic surgery Clues from Comorbidity:
profession—but it is bad business. These ➢​ Comorbidity with OCD: BDD often
patients do not benefit from surgery co-occurs with OCD, suggesting
and may return for additional surgery possible shared underlying
or, on occasion, file malpractice causes.
lawsuits. Investigators estimate that as ➢​ 2. Comorbidity with Eating
many as 8% to 25% of all patients who Disorders: 15% of people with
request plastic surgery may have BDD eating disorders also have BDD,
(Barnard, 2000; Crerand et al., 2004). The with body concerns unrelated to
most common procedures are weight and shape.
rhinoplasties (nose jobs), facelifts, 3.​ Unknown Causes:
eyebrow elevations, liposuction, breast ➢​ Genetic Contribution: There is
augmentation, and surgery to alter the almost no information on
jawline. whether it runs in families, so we
●​ The problem is that surgery on the can’t investigate a specific genetic
proportion of these people with BDD contribution.
seldom produces the desired results. ➢​ Biological and Psychological
These individuals return for additional Vulnerabilities: There's limited
surgery on the same defect or information on biological and
concentrate on some new defect. psychological factors that might
Phillips, Menard, Fay, and Pagano (2005) contribute to BDD.
report that 81% of 50 individuals
seeking surgery or similar medical
TREATMENT
consults were dissatisfied with the
result.
●​ Drugs that block the reuptake of
serotonin, such as clomipramine
CAUSES (Anafranil) and fluvoxamine (Luvox),
provide relief to at least some people
1.​ Known Causes: None (Hadley, Kim, Priday, & Hollander, 2006).
●​ Second, exposure and response
2.​ Speculated Causes: prevention, the type of
➢​ Displacement: A psychological cognitive-behavioral therapy effective
defense mechanism where with OCD, has also been successful with
unconscious conflicts are BDD (McKay et al., 1997; Rosen, Reiter, &
redirected to a body part. Orosan, 1995; Veale, Gournay, et al., 1996;
➢​ Similarities to OCD: BDD might Wilhelm, Otto, Lohr, & Deckersbach,
share similar causes with OCD, 1999).
given their similarities in
symptoms and comorbidity
(What is comorbidity? This is a

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overcrowding, extremely unsanitary

C3 HOARDING DISORDER
conditions).
●​ Animal hoarding may be a special
●​ Hoarding disorder is characterized by manifestation of hoarding disorder. Most
persistent difficulty discarding or individuals who hoard animals also hoard
parting with possessions, regardless of inanimate objects. The most prominent
their actual value, as a result of a differences between animal and object
strong perceived need to save the hoarding are the extent of unsanitary
items and to distress associated with conditions and the poorer insight in
discarding them. animal hoarding.
●​ Hoarding disorder differs from normal
collecting.
●​ The three major characteristics of this EXAMPLE
problem are excessive acquisition of
things, difficulty discarding anything, 1.​ For example, symptoms of hoarding
and living with excessive clutter under disorder result in the accumulation of a
conditions best characterized as gross large number of possessions that
disorganization. congest and clutter active living areas to
●​ Hoarding behavior can begin early in life the extent that their intended use is
and get worse with each passing decade. substantially compromised. The
●​ People with the disorder experience excessive acquisition form of hoarding
strong anxiety and distress about disorder, which characterizes most but
throwing anything away, because not all individuals with hoarding disorder,
everything has either some potential use consists of excessive collecting, buying,
or sentimental value in their minds, or or stealing of items that are not needed
simply becomes an extension of their or for which there is no available space.
own identity. Their homes or apartments 2.​ One patient’s house and yard was
may become almost impossible to live in. condemned, because junk was piled so
Most of these individuals don’t consider high it was both unsightly and a fire
that they have a problem until family hazard. Among her hoard was a 20-year
members or authorities insist that they collection of used sanitary napkins!
seek help. Although only a tiny percentage of fires
in residences occur in the homes of
ANIMAL HOARDING individuals who hoard, these fires
account for 24% of all fire related fatalities
(Frost et al., 2012).
●​ Animal hoarding can be defined as the
3.​ Rainie, a 45-year-old artist, lived in a
accumulation of a large number of
small studio apartment that was
animals and a failure to provide minimal
overflowing with art supplies, clothes,
standards of nutrition, sanitation, and
books, and household items. The
veterinary care and to act on the
apartment was cluttered to the point
deteriorating condition of the animals
where it was difficult to move around,
(including disease, starvation, or death)
and the smell of rotting food and mold
and the environment (e.g., severe

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filled the air. Rainie had difficulty

occupational, or other important areas of
discarding any of her possessions, functioning (including maintaining a safe
regardless of their value, because she felt environment for self and others). E. The
a strong emotional attachment to each hoarding is not attributable to another
item. She believed that each item might medical condition (e.g., brain injury,
be useful someday or held sentimental cerebrovascular disease, Prader-Willi
value. Rainie's friends and family had syndrome).
tried to help her clean and declutter her
F. The hoarding is not better explained by
apartment, but she became extremely the symptoms of another mental disorder
distressed and anxious whenever they (e.g., obsessions in obsessive-compulsive
tried to throw anything away. As a result, disorder, decreased energy in major
Rainie's apartment had become a fire depressive disorder, delusions in
hazard, and her friends and family were schizophrenia or another psychotic
disorder, cognitive deficits in major
worried about her safety. Rainie's
neurocognitive disorder, restricted interests
hoarding had also caused her to become
in autism spectrum disorder).
isolated and withdrawn, as she was
ashamed to have anyone visit her home. Specify if:
Despite the chaos and danger of her
living situation, Rainie continued to With excessive acquisition: If difficulty
acquire more possessions, often buying discarding possessions is accompanied by
items she didn't need or have space for. excessive acquisition of items that are not
needed or for which there is no available
space.
DIAGNOSTIC CRITERIA FOR
HOARDING DISORDER With good or fair insight: The individual
recognizes that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding
A. Persistent difficulty discarding or parting items, clutter, or excessive acquisition) are
with possessions, regardless of their actual problematic.
value. With poor insight: The individual is mostly
convinced that hoarding-related beliefs and
B. This difficulty is due to a perceived need
to save the items and to distress associated behaviors (pertaining to difficulty discarding
with discarding them. items, clutter, or excessive acquisition) are not
problematic despite evidence to the contrary.
C. The difficulty discarding possessions With absent insight/delusional beliefs: The
results in the accumulation of possessions individual is completely convinced that
that congest and clutter active living areas
hoarding-related beliefs and behaviors
and substantially compromises their
intended use. If living areas are uncluttered, (pertaining to difficulty discarding items,
it is only because of the interventions of clutter, or excessive acquisition) are not
third parties (e.g., family members, problematic despite evidence to the contrary.
cleaners, authorities).

D. The hoarding causes clinically

significant distress or impairment in social,

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

●​ Rainie's symptoms are classic examples

SAMPLE CASE INTERPRETATION
(BASED ON THE DIAGNOSTIC of Hoarding Disorder, and her case meets
CRITERIA OF HOARDING DISORDER) all the diagnostic criteria for the disorder.
Additionally, Rainie's excessive
acquisition of items she doesn't need or
●​ Rainie's case meets all the diagnostic
have space for suggests that she also
criteria for Hoarding Disorder. Firstly,
meets the criteria for "With excessive
Rainie exhibits persistent difficulty
acquisition".
discarding or parting with possessions,
regardless of their actual value (Criteria
A). She feels a strong emotional STATISTICS
attachment to each item and believes
that each item might be useful someday ●​ Nationally representative prevalence
or holds sentimental value. studies of hoarding disorder are not
●​ Secondly, Rainie's difficulty discarding available. Community surveys estimate
possessions is due to a perceived need to the point prevalence of clinically
save the items and distress associated significant hoarding in the United States
with discarding them (Criteria B). She and Europe to be approximately 2%-6%.
becomes extremely distressed and ●​ Hoarding disorder affects both males
anxious whenever anyone tries to throw and females, but some epidemiological
anything away. studies have reported a significantly
●​ Thirdly, the difficulty discarding greater prevalence among males.
possessions results in the accumulation ●​ This contrasts with clinical samples,
of possessions that congest and clutter which are predominantly female.
active living areas and substantially Hoarding symptoms appear to be
compromise their intended use (Criteria almost three times more prevalent in
C). Rainie's apartment is cluttered to the older adults (ages 55-94 years)
point where it's difficult to move around, compared with younger adults (ages
and the smell of rotting food and mold 34-44 years).
fills the air.
●​ Fourthly, the hoarding causes clinically CAUSES
significant distress or impairment in
social, occupational, or other important
1.​ It's not clear what causes hoarding
areas of functioning (Criteria D).
disorder. Genetics, brain function and
●​ Rainie's hoarding has caused her to
stressful life events are being studied as
become isolated and withdrawn, and her
possible causes (Mayo Clinic, 2023).
friends and family are worried about her
2.​ Comorbidity: Approximately 75% of
safety due to the fire hazard posed by the
individuals with hoarding disorder have a
clutter. Finally, the hoarding is not
comorbid mood or anxiety disorder. The
attributable to another medical condition
most common comorbid conditions are
(Criteria E) or better explained by the
major depressive disorder (up to 50% of
symptoms of another mental disorder
cases), social anxiety disorder (social
(Criteria F).
phobia), and generalized anxiety

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

disorder. Approximately 20% of or when attempting to resist the urge to

individuals with hoarding disorder also pull), or may lead to gratification,
have symptoms that meet diagnostic pleasure, or a sense of relief when the
criteria for OCD. These comorbidities may hair is pulled out.
often be the main reason for
consultation, because individuals are EXAMPLE
unlikely to spontaneously report
hoarding symptoms, and these
symptoms are often not asked about in Penelope, a 25-year-old graphic designer, had
routine clinical interviews. been pulling out her hair for the past 5 years.
She would often find herself pulling out
strands of hair from her scalp, eyebrows, and
TREATMENTS
eyelashes when she was stressed, bored, or
anxious. Despite her efforts to stop, Penelope
●​ CBT (Cognitive Behavioral Therapy) is a
couldn't resist the urge to pull out her hair,
promising treatment for hoarding
resulting in noticeable hair loss on her scalp
disorder (Tolin, Frost, Steketee, & Muroff,
and sparse eyebrows. Penelope felt
2015). These treatments developed at our
embarrassed and ashamed about her hair
clinic teach people to assign different
pulling, and she avoided social gatherings and
values to objects and to reduce anxiety
photo opportunities because she didn't want
about throwing away items that are
others to see her hair loss. She had tried to
somewhat less valued (Grisham et al.,
hide her hair loss with hats, wigs, and
2012; Steketee & Frost, 2007a).
makeup, but it only made her feel more
anxious and self-conscious. Penelope’s hair
C4 TRICHOTILLOMANIA (HAIR-PULLING pulling had also affected her work
DISORDER performance, as she would often find herself
pulling out hair during meetings or while
●​ The urge to pull out one’s own hair from working on projects.
anywhere on the body, including the
scalp, eyebrows, and arms.
●​ This behavior results in noticeable hair DIAGNOSTIC CRITERIA FOR
loss, distress, and significant social TRICHOTILLOMANIA
impairments.
●​ This disorder can often have severe social
A. Recurrent pulling out of one’s hair,
consequences, and, as a result, those resulting in hair loss.
affected can go to great lengths to
conceal their behavior. B. Repeated attempts to decrease or stop
●​ Hair pulling may also be preceded or hair pulling.
accompanied by various emotional
C. The hair pulling causes clinically
states; it may be triggered by feelings of
significant distress or impairment in social,
anxiety or boredom, may be preceded by occupational, or other important areas of
an increasing sense of tension (either functioning.
immediately before pulling out the hair

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

caused by an underlying medical

D. The hair pulling or hair loss is not
attributable to another medical condition condition.
(e.g., a dermatological condition). ●​ Finally, Penelope's hair pulling is not
better explained by the symptoms of
E. Hair pulling is not better explained by the another mental disorder, such as body
symptoms of another mental disorder (e.g., dysmorphic disorder (Criteria E). While
attempts to improve a perceived defect or Penelope does experience distress and
flaw in appearance in body dysmorphic
impairment related to her appearance,
disorder).
her primary concern is the urge to pull
out her hair, rather than a perceived
SAMPLE CASE INTERPRETATION defect or flaw in her appearance.
(BASED ON THE DIAGNOSTIC
CRITERIA OF TRICHOTILLOMANIA) STATISTICS

●​ Penelope’s case meets all the diagnostic ●​ In the general population, the 12-month
criteria for Trichotillomania. Firstly, she prevalence estimate for trichotillomania
exhibits recurrent pulling out of her hair, in adults and adolescents is l%-2%.
resulting in noticeable hair loss (Criteria ●​ Females are more frequently affected
A). Penelope’s hair pulling is not just a than males, at a ratio of approximately
one-time incident, but rather a repeated 10:1.
behavior that she's been struggling with ●​ Among children with trichotillomania,
for years. males and females are more equally
●​ Secondly, she has made repeated represented.
attempts to decrease or stop hair pulling, ●​ Onset of hair pulling in trichotillomania
but has been unable to resist the urge most commonly coincides with, or
(Criteria B). Emily's efforts to hide her hair follows the onset of, puberty.
loss and avoid situations that might
trigger her hair pulling also demonstrate
CAUSES
her attempts to stop the behavior.
●​ Thirdly, Penelope’s hair pulling causes
clinically significant distress and 1.​ There may be some genetic influence
impairment in social, occupational, and on trichotillomania, with one study
other areas of functioning (Criteria C). Her finding a unique genetic mutation in a
hair pulling has affected her self-esteem, small number of people (Zuchner et al.,
social relationships, and work 2006).
performance, causing her significant 2.​ Genetic and physiological: There is
emotional distress. evidence for a genetic vulnerability to
●​ Fourthly, Penelope’s hair pulling is not trichotillomania. The disorder is more
attributable to another medical common in individuals with
condition, such as a dermatological obsessive-compulsive disorder (OCD)
condition (Criteria D). There is no and their first-degree relatives than in
indication that Penelope’s hair pulling is the general population.

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

Individuals may pick at healthy skin, at

TREATMENT
minor skin irregularities, at lesions such
as pimples or calluses, or at scabs from
●​ Psychological treatments, particularly previous picking.
an approach called “habit reversal ●​ Most individuals pick with their
training,” has the most evidence for fingernails, although many use tweezers,
success with Trichotillomania. pins, or other objects. In addition to skin
●​ In this treatment, patients are carefully picking, there may be skin rubbing,
taught to be more aware of their squeezing, lancing, and biting.
repetitive behavior, particularly as it is ●​ Individuals with excoriation disorder
just about to begin, and to then often spend significant amounts of time
substitute a different behavior, such as on their picking behavior, sometimes
chewing gum, applying a soothing lotion several hours per day, and such skin
to the skin, or some other reasonably picking may endure for months or
pleasurable but harmless behavior. years.
●​ Results may be evident in as little as four ●​ Skin picking may be triggered by
sessions, but the procedure requires feelings of anxiety or boredom, may be
teamwork between the patient and preceded by an increasing sense of
therapist and close monitoring of the tension (either immediately before
behavior throughout the day (Nock et al., picking the skin or when attempting to
2011). resist the urge to pick), and may lead to
●​ Drug treatments, mostly gratification, pleasure, or a sense of relief
serotonin-specific reuptake inhibitors, when the skin or scab has been picked.
hold some promise, particularly for ●​ Excoriation is also largely a female
trichotillomania (Chamberlain, Menzies, disorder.
Sahakian, & Fineberg, 2007).

EXAMPLE
C5 EXCORIATION (SKIN-PICKING
DISORDER)
1.​ In one case, a young woman spent 2 to 3
hours a day picking her skin, resulting in
●​ It is characterized, as the label implies, by numerous scabs, scars, and open
repetitive and compulsive picking of the wounds on her face. As a result she
skin, leading to tissue damage. would often be late for work or unable to
●​ Skin picking may be accompanied by a work if the open wounds were too bad.
range of behaviors or rituals involving She had not socialized with friends for
skin or scabs. Thus, individuals may over a year.
search for a particular kind of scab to
pull, and they may examine, play with, or
mouth or swallow the skin after it has DIAGNOSTIC CRITERIA FOR
been pulled. EXCORIATION
●​ The most commonly picked sites are
the face, arms, and hands, but many A. Recurrent skin picking resulting in skin
individuals pick from multiple body sites.

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frequent lateness or inability to work, and

lesions.
her avoidance of socializing with friends
B. Repeated attempts to decrease or stop for over a year (Criteria C).
skin picking. ●​ Finally, there is no indication that the
skin picking is attributable to the
C. The skin picking causes clinically physiological effects of a substance or
significant distress or impairment in social, another medical condition (Criteria D), or
occupational, or other important areas of
that it is better explained by symptoms
functioning.
of another mental disorder (Criteria E).
D. The skin picking is not attributable to Therefore, the young woman's symptoms
the physiological effects of a substance are consistent with Excoriation (Skin
(e.g., cocaine) or another medical condition Picking) Disorder.
(e.g., scabies).

E. The skin picking is not better explained STATISTICS

by symptoms of another mental disorder
(e.g., delusions or tactile hallucinations in a
●​ In the general population, the lifetime
psychotic disorder, attempts to improve a
prevalence for excoriation disorder in
perceived defect or flaw in appearance in
body dysmorphic disorder, stereotypies in adults is 1.4% or somewhat higher.
stereotypic movement disorder, or ●​ Three-quarters or more of individuals
intention to harm oneself in nonsuicidal with the disorder are female.
self-injury). ●​ Although individuals with excoriation
disorder may present at various ages, the
skin picking most often has onset during
SAMPLE CASE INTERPRETATION adolescence, commonly coinciding with
(BASED ON THE DIAGNOSTIC
or following the onset of puberty.
CRITERIA OF EXCORIATION)

CAUSES
●​ The young woman in the sample case
meets all the diagnostic criteria for
Excoriation (Skin Picking) Disorder. 1.​ Excoriation disorder is more common in
Firstly, she exhibits recurrent skin picking individuals with obsessive-compulsive
resulting in skin lesions, including disorder (OCD) and their first-degree
numerous scabs, scars, and open family members than in the general
wounds on her face (Criteria A). population.
●​ Secondly, it is implied that she has made 2.​ Comorbidity: it has been established
repeated attempts to decrease or stop that these disorders often co-occur with
skin picking, as she is aware of the obsessive-compulsive disorder and body
negative consequences of her behavior dysmorphic disorder, as well as with each
(Criteria B). other.(Shaw & King, 2024).
●​ Thirdly, the skin picking causes clinically 3.​ Experts think that several factors play the
significant distress or impairment in role in causing excoriation
social, occupational, or other important 4.​ Differences in brain structure: People
areas of functioning, as evidenced by her with excoriation may have differences in

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

the area of their brain that controls how Associated Features:

they learn habits (Shaw & King, 2024). ➔​ Cognitive features include attention
5.​ Stress, anxiety, or other conditions: focused on somatic symptoms,
Some people with stress, anxiety, or attribution of normal bodily sensations to
depression may soothe themselves by physical illness, worry about illness, a self
picking at their skin (Shaw & King, 2024). concept of bodily weakness, and
6.​ Genetics: You are more likely to have intolerance of bodily complaints.
skin-picking disorder if your parents, ➔​ Besides health anxiety, emotional
siblings, or children also have the features may include negative affectivity,
condition (Shaw & King, 2024). desperation, and demoralization related
to somatic symptoms. - Individuals with
this disorder typically present to general
TREATMENT
medical health services rather than
mental health services.
●​ Psychological treatments, particularly an
approach called “habit reversal
training,” has the most evidence for DIAGNOSTIC CRITERIA FOR SOMATIC
success with Excoriation disorder. In this SYMPTOM DISORDER
treatment, patients are carefully taught
to be more aware of their repetitive A. One or more somatic symptoms that are
behavior, particularly as it is just about to distressing or have significant disruption of
begin, and to then substitute a different daily life.
behavior, such as chewing gum, applying
a soothing lotion to the skin, or some B. Excessive thoughts, feelings, or
other reasonably pleasurable but behaviors related to somatic symptoms,
manifested by at least one:
harmless behavior.
●​ Drug treatments, mostly 1. Persistent thoughts about the seriousness
serotonin-specific reuptake inhibitors, of symptoms.
hold some promise but the results have 2. Persistently high level of anxiety about
been mixed with excoriation. health.
3. Excessive time and energy devoted to
D SOMATIC SYMPTOM AND RELATED health concerns.
DISORDERS
C. Symptoms persist typically more than 6
months.
Somatic Symptom Disorder
●​ Disproportionately excessive response Specify if: with predominant pain –
(thoughts, feelings, or behaviors) to a symptoms predominantly involve pain.
distressing physical symptom Persistent – more than 6 months.
●​ One or more somatic symptoms that are Severity:
distressing or result in significant Mild – one symptom specified in criterion B is
disruption fulfilled.
●​ Usually persists at least 6 months Moderate – two or more symptoms

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Severe – two or more symptoms in criterion B D. The individual performs excessive

and three multiple somatic complaints. health-related behaviors (check for signs)
Prevalence of 5%-7% or exhibits maladaptive avoidance (Avoid
doctor appointments and hospitals).

E. Illness preoccupation present for at least

D1 ILLNESS ANXIETY DISORDER (≥ 6 mos)
6 months.

●​ Also known as hypochondriasis F. The illness-related preoccupation is not

●​ Excessive worry over having a serious better explained by another mental
illness, despite minimal medical evidence disorder.
●​ High level of anxiety around health
Specifiers:
overall
●​ Care-seeking type – medical care,
●​ Excessive health-related activities
including physician visits or
(symptom checking, test, doctor visits,
undergoing tests and procedures.
etc.) or avoids medical care
●​ Care-avoidant type – medical care is
Associated Features:
rarely used.
➔​ Individuals with this disorder are
encountered far more frequently in
medical than in mental health settings. D2 FUNCTIONAL NEUROLOGICAL
➔​ They often consult multiple physicians SYMPTOM DISORDER (CONVERSION
for the same problem and obtain DISORDER
repeatedly negative diagnostic test
results. ●​ Physical malfunctioning
➔​ Individuals with this disorder are ●​ Abnormal voluntary motor or sensory
generally dissatisfied with their medical functioning
care and find it unhelpful, often feeling ●​ Symptoms are incompatible with
they are not being taken seriously by recognized neurologic or medical
physicians. conditions
●​ Marked distress or impairment
DIAGNOSTIC CRITERIA FOR ILLNESS DIAGNOSTIC CRITERIA FOR
ANXIETY DISORDER FUNCTIONAL NEUROLOGICAL
“HYPOCHONDRIASIS” SYMPTOM DISORDER (CONVERSION
DISORDER

A. Preoccupation with having or acquiring

serious illness. A. One or more symptoms of altered
voluntary motor.
B. Somatic symptoms are not present or, if
present, are only mild in intensity. B. Clinical findings provide evidence of
incompatibility between the symptom and
C. There is a high level of anxiety about condition.
health.

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➔​ Individuals with factitious disorder

C. Symptoms are not better explained by
another mental disorder. imposed on another sometimes falsely
allege the presence of educational
D. Symptoms cause clinically significant deficits or disabilities in their children for
distress or impairment. which they demand special attention,
often at considerable inconvenience to
Specify symptom type: education professionals.
●​ with weakness or paralysis
●​ with abnormal movement
●​ with swallowing symptoms DIAGNOSTIC CRITERIA FOR
●​ with speech symptoms FACTITIOUS DISORDER
●​ with attacks or seizures
●​ with anesthesia or sensory loss
IMPOSED ON SELF
●​ with special sensory symptom
●​ with mixed symptom A. Falsification of physical or physiological
signs or symptoms, or induction of injury or
Prevalence of 5%. Incidence of individual disease, associated with identified
persistent conversion symptoms is estimated deception.
to be 2-5/100,000 per year.
B. Individual presents himself or herself to
others as ill, impaired, or injured

D3 FACTITIOUS DISORDER C. Deceptive behavior evident even in

absence of obvious rewards.
●​ Also known as Munchausen Syndrome
D. Behavior is not better explained by
●​ Intentionally faking to achieve a sick role
another mental disorder such as delusional
●​ No clear economic or legal motivators
disorder.
●​ Falsification of physical and
psychological signs or symptoms, or IMPOSE ON ANOTHER
induction of injury or disease, associated
with identified deception A. Falsification of signs, symptoms, injury or
●​ Deceptive behavior is evident even in the diseases in another, associated with
absence of obvious external rewards. identified deception.
Types of Factitious Disorder
1.​ Imposed on Self: present himself or B. The individual presents another
herself as ill individual (victim) to others as ill, impaired,
2.​ Imposed on Another: presents another or injured.
individual as ill
C. Deceptive behavior is evident even in
Associated Features: absence of obvious rewards.
➔​ Individuals with the disorder are at risk
D. Behavior is not better explained by
for experiencing great psychological
another mental disorder.
distress or functional impairment by
causing harm to themselves and others.

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

Diagnosis requires demonstrating that an E DISSOCIATIVE DISORDERS

individual is taking surreptitious actions to
misrepresent, simulate, or cause signs or ●​ Dissociation occurs when individuals feel
symptoms of illness or injury in absence of detached from themselves or their
obvious external rewards. surroundings, as if they are dreaming or
moving in slow motion. Morton Prince
recognized over a century ago that many
D4 DIAGNOSTIC CRITERIA FOR people occasionally experience
PHYSIOLOGICAL FACTORS AFFECTING dissociation, often triggered by extreme
OTHER MEDICAL CONDITIONS stress, accidents, or sleep deprivation.
While some may not find it distressing,
others experience fear.
A. A medical condition other than a mental
disorder is present. EXAMPLE

B. Psychological or behavioral factors affect

the medical condition in one of the ●​ A Stanford University study examined
following ways: journalists' reactions to witnessing the
execution of Robert Alton Harris, a
1. Close temporal association between traumatic event marked by multiple
psychological factors and the development/ delays. Many journalists, sleep-deprived
from staying up all night, later reported
delayed recovery from medical conditions.
dissociative symptoms, such as feeling
2. The factors interfere with the treatment of
unreal, detached from others, or
medical conditions. estranged from their emotions. These
3. The factors constitute additional experiences fall into two categories:
well-established health risks for the individual. depersonalization, where individuals feel
4. The factors influence the underlying disconnected from themselves, and
pathophysiology, precipitating or derealization, where the external world
appears distorted or unreal. Such
exacerbating symptoms or necessitating
dissociative episodes serve as a
medical attention. psychological mechanism to detach from
reality and are common in dissociative
C. Factors in criterion B are not better disorders, which disrupt one’s sense of
explained by another mental disorder. identity, awareness, and memory.
●​ Disintegrated experiences occur when
Severity: individuals lose their sense of identity,
Mild – increases medical risk. reality, or memory—sometimes even
Moderation – aggravates underlying medical adopting a different personality with
distinct memories and physical reactions.
conditions.
These disruptions affect one's
Severe – results in medical hospitalization or relationship with the self, the world, and
emergency room visit. memory. While much is still unknown
Extreme – life-threatening risk. about these conditions, two key disorders
are depersonalization-derealization
disorder and dissociative amnesia,
which precede the more complex
dissociative identity disorder. Social and

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cultural factors strongly influence

dissociative disorders, shaping how
symptoms manifest, even in severe
cases. SYMPTOM

●​ Depersonalization Symptoms (Feeling

E1 DEPERSONALIZATION- Detached from Self)
DEREALIZATION DISORDER ➢​ Feeling like an outside observer of
one’s own thoughts, body, or
actions.
➢​ A sense of watching oneself in a
●​ Depersonalization-derealization disorder dream or movie.
is a rare condition where severe and ➢​ Emotional numbness or lack of
distressing feelings of unreality dominate connection to emotions.
a person’s life, disrupting normal ➢​ A distorted sense of time (e.g.,
functioning events feeling unreal or distant)
➢​ Physical sensations feeling
BONNIE DANCING AWAY FROM strange or unfamiliar.
HIMSELF -​
●​ Derealization Symptoms (Feeling
Detached from Reality)
Bonnie, a dance teacher in her late 20s, was ➢​ The external world seems unreal,
accompanied by her husband when she first foggy, or dreamlike.
➢​ Objects or surroundings appear
visited the clinic and complained of “flipping
distorted in shape, size, or color.
out.” When asked what she meant, she said,
➢​ People seem mechanical, distant,
“It’s the scariest thing in the world. It often or unfamiliar.
happens when I’m teaching my modern ➢​ A sense that time is speeding up
dance class. I’ll be up in front, and I will feel or slowing down.
focused on. Then, as I’m demonstrating the ➢​ Difficulty connecting with or
steps, I just feel like it’s not really me and that I recognizing familiar places or
things.
don’t really have control of my legs.
-​
Sometimes I feel like I’m standing in back of
●​ These symptoms can be persistent or
myself just watching. Also I get tunnel vision. episodic and often lead to significant
It seems like I can only see in a narrow space distress and impairment in daily life.
right in front of me and I just get totally
separated from what’s going on around me.
DIAGNOSTIC CRITERIA FOR
Then I begin to panic and perspire and shake.” DEPERSONALIZATION-
It turns out that Bonnie’s problems began DEREALIZATION DISORDER
after she smoked marijuana for the first time
about 10 years before. She had the same
feeling then and found it scary, but with the A. The presence of persistent or recurrent
help of friends she got through it. Lately the experiences of depersonalization,
derealization, or both:
feeling recurred more often and more
severely, particularly when she was teaching Depersonalization: Experiences of unreality,
dance class. detachment, or being an outside observer

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

memory loss. It has different patterns,

with respect to one’s thoughts, feelings,
including generalized amnesia, where
sensations, body or actions (e.g., perceptual
individuals forget everything about
alterations, distorted sense of time, unreal or
themselves, including their identity. This
absent self, emotional and/or physical
condition can be lifelong or extend back
numbing).
to a specific period, such as several
Derealization: Experiences of unreality or
months or a year.
detachment with respect to surroundings
(e.g., individuals or objects are experienced as
unreal, dreamlike, foggy, lifeless, or visually THE WOMAN WHO LOST
distorted) HER MEMORY

B. During the depersonalization or

derealization experience, reality testing Several years ago, a woman in her early 50s
remains intact. brought her daughter to one of our clinics
because of the girl’s refusal to attend school
C. The symptoms cause clinically significant
and other severely disruptive behavior. The
distress or impairment in social,
occupational, or other important areas of father, who refused to come to the session,
functioning. was quarrelsome, a heavy drinker, and, on
occasion, abusive. The girl’s brother, now in his
D. The disturbance is not attributable to the mid-20s, lived at home and was a burden on
physiological effects of a substance (e.g., a the family. Several times a week a major battle
drug of abuse, medication) or another erupted, complete with shouting, pushing,
medical condition (e.g., seizures).
and shoving, as each member of the family
E. The disturbance is not better explained blamed the others for all their problems. The
by another mental disorder, such as mother, a strong woman, was clearly the
schizophrenia or panic disorder. peacemaker responsible for holding the
family together. Approximately every 6
NOTE: Research links depersonalization disorder months, usually after a family battle, the
to specific brain function abnormalities, mother lost her memory and the family had
particularly in emotional processing and her admitted to the hospital. After a few days
perception. Studies show that individuals with away from the turmoil, the mother regained
the disorder have reduced emotional responses, her memory and went home, only to repeat
likely due to selective inhibition of emotions.
the cycle in the coming months. Although we
Brain imaging confirms deficits in perception
and emotion regulation, and HPA axis did not treat this family (they lived too far
dysregulation suggests further emotional away), the situation resolved itself when the
processing issues. Despite these findings, children moved away and the stress
psychological treatments remain understudied, decreased.
and Prozac has shown no significant benefit
over a placebo.
NOTE:

E2 DISSOCIATIVE AMNESIA ●​ Localized or selective amnesia is more

common than generalized amnesia and
involves the inability to recall specific
●​ Dissociative amnesia is a severe traumatic events. It is frequently
dissociative disorder characterized by observed in war veterans and trauma

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survivors. In some cases, individuals may

of a closed head injury/traumatic brain
remember events factually but lack
injury, or other neurological condition).
emotional recollection, as seen in a
woman who recalled past trauma in
D. The disturbance is not better explained
therapy but only emotionally relieved it
by dissociative identity disorder,
under hypnosis. This emotional
posttraumatic stress disorder, acute stress
detachment is also seen in
disorder, somatic symptom disorder, or
depersonalization-derealization
major or mild neurocognitive disorder.
disorder. Unlike cognitive disorders like
dementia, dissociative amnesia primarily
Specify if:
affects memory for traumatic events
With dissociative fugue: Apparently
rather than general memory loss.
purposeful travel or bewildered wandering
that is associated with amnesia for identity or
for other important autobiographical
●​ Dissociative fugue, a subtype of
information.
dissociative amnesia, involves sudden,
unexpected travel with memory loss
surrounding the journey. Individuals may NOTE:
find themselves in a new place without
remembering how they got there, often ●​ Dissociative amnesia typically begins in
fleeing an intolerable situation. In some adolescence or adulthood and is rare
cases, they assume a new identity or after age 50. It is the most common
become confused about their original dissociative disorder, affecting 1.8% to
one. 7.3% of the population. Fugue states
often end abruptly, with individuals
regaining their memories and returning
DIAGNOSTIC CRITERIA FOR
home. These states involve more than
DISSOCIATIVE AMNESIA
just memory loss—they include identity
disruption, sometimes leading to the
adoption of a new identity.
A. An inability to recall important ●​ A culturally specific dissociative state
autobiographical information, usually of a called amok, mostly seen in males
traumatic or stressful nature, that is outside Western cultures, involves a
inconsistent with ordinary forgetting. Note: trancelike state where individuals may
Dissociative amnesia most often consists of violently attack or kill others before
localized or selective amnesia for a specific regaining awareness.
event or events; or generalized amnesia for
identity and life history.

B. The symptoms cause clinically significant

distress or impairment in social,
occupational, or other important areas of
functioning.

C. TThe disturbance is not attributable to

the physiological effects of a substance
(e.g., alcohol or other drug of abuse, a
medication) or a neurological or other
medical condition (e.g., partial complex
seizures, transient global amnesia, sequelae

PAGE 38 ROBERTO, KURT, KATLEEN, SHARMAIN – BS PSYCHOLOGY 3-1 (CVSU TMC)

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

average is around 15. These identities

DIFFERENCES BETWEEN DA AND
may have distinct behaviors, voices,
AMNESIA IN COGNITIVE DISORDERS
and gestures, but they are often only
partially independent, rather than fully
formed personalities. Due to this, the
disorder was renamed from Multiple
Personality Disorder to Dissociative
Identity Disorder (DID) in the DSM-IV.

EXAMPLE

During Jonah’s hospitalization, doctors

observed that he exhibited three distinct
identities, or alters, besides his primary
identity. These included:

●​ Sammy – Rational, calm, and in control

●​ King Young – Focused on sexual
activity and relationships
●​ Usoffa Abdulla – Violent and
dangerous

Jonah himself was unaware of his alters, while

Sammy had the most awareness of the
others. King Young and Usoffa Abdulla had
limited, indirect knowledge of the different
personalities. This case highlights the
fragmented nature of Dissociative Identity
Disorder (DID)

NOTE:

Jonah's dissociative identities emerged in

response to traumatic events during childhood:

●​ Sammy appeared at age 6 after

witnessing his mother stab his father.
●​ King Young emerged when Jonah's
mother dressed him as a girl in private.
E3 DISSOCIATIVE IDENTITY DISORDER ●​ Usoffa Abdulla developed after Jonah
was attacked by a group of white
youths, with the sole purpose of
●​ Dissociative Identity Disorder (DID) protecting him.
involves the presence of multiple
According to DSM-5, Dissociative Identity
identities, with individuals adopting up to
Disorder (DID) involves amnesia and identity
100 different identities, though the

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BPSY 107 FIRST SEMESTER– MA’AM LORELEI SOBREMONTE– TUESDAY & WEDNESDAY

fragmentation. The number of personalities is

disruption of marked discontinuity in sense
less important than the dissociation of identity,
of self and sense of agency, accompanied
which is the core feature of the disorder.
by related alterations in affect, behavior,
consciousness, memory, perception,
SYMPTOMS cognition, and/or sensory-motor
functioning. These signs and symptoms
may be observed by others or reported by
●​ Presence of Multiple Identities (Alters)
the individual.
– Individuals may have two or more
distinct identities that take control at
B. Recurrent gaps in the recall of everyday
different times.
events, important personal information,
●​ Memory Gaps (Amnesia) – Inability to
and/or traumatic events that are
recall personal information, traumatic
inconsistent with ordinary forgetting.
events, or experiences from different
identities.
C. The symptoms cause clinically significant
●​ Identity Fragmentation – Different alters
distress or impairment in social,
may have unique behaviors, voices,
occupational, or other important areas of
mannerisms, and preferences.
functioning.
●​ Switching Between Identities – Sudden
shifts in personality, often triggered by
D. The disturbance is not a normal part of a
stress or trauma reminders.
broadly accepted cultural or religious
●​ Depersonalization & Derealization –
practice. Note: In children, the symptoms
Feeling detached from oneself or that
are not attributable to imaginary playmates
the world is unreal.
or other fantasy play.
●​ Emotional Dysregulation – Severe mood
swings, anxiety, depression, or self-harm E. The symptoms are not attributable to the
tendencies. physiological effects of a substance (e.g.,
●​ Disruptions in Daily Life – Difficulties blackouts or chaotic behavior during
with relationships, work, and maintaining alcohol intoxication) or another medical
a stable identity. condition (e.g., complex partial seizures).
●​ Different Levels of Awareness Among
Alters – Some personalities may be
aware of others, while some may not.
STATISTICS
●​ Changes in Physical Responses – Some
alters may have different allergies,
handwriting, or even physiological ●​ Prevalence: Affects about 1% to 1.5% of
responses. the general population, with higher rates
●​ Trauma History – Often linked to severe in psychiatric patients.
childhood trauma or abuse. ●​ Gender Differences: More common in
women (3:1 to 9:1 ratio compared to men).
●​ Onset Age: Symptoms usually begin in
DIAGNOSTIC CRITERIA FOR
childhood (ages 5–10) but are often
DISSOCIATIVE IDENTITY DISORDER
diagnosed in adulthood (ages 20–40).
●​ Number of Alters: Individuals may have
10 to 15 identities, with some cases
A. Disruption of identity characterized by exceeding 100.
two or more distinct personality states, ●​ Trauma Link: Over 90% of cases involve
which may be described in some cultures severe childhood trauma (abuse, neglect,
as an experience of possession. The or violence).

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●​ Comorbid Conditions: Strong REFERENCES:

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