Trauma - Stressor Related Disorder

Trauma and Stressor-Related
Disorders
mirjam nilsson
TRAUMA – STRESSOR
RELATED DISORDERS
1
DISSOCIATIVE DISORDER
2
Agenda SOMATIC SYMPTOMS AND
RELATED DISORDERS
3
introduction
DSM-5 consolidates a group of
formerly disparate disorders that
Click icon to add picture
all develop after a relatively
stressful life event, often an
extremely stressful or traumatic
life event.
20XX presentation title 3

This set of disorders—trauma and stressor-related disorders—
include attachment disorders in childhood following inadequate
or abusive child-rearing practices, adjustment disorders
characterized by persistent anxiety and depression following a
stressful life event, and reactions to trauma such as posttraumatic
stress disorder and acute stress disorder
DSM-5 consolidates a group of
formerly disparate disorders that
all develop after a relatively
stressful life event, often an
extremely stressful or traumatic
life event.

Investigators working in this area concluded that these
disorders did not fit as neatly with other classes of
disorders, such as anxiety disorders as previously
Click icon
assumed.
This is because trauma and stressor-related disorders
all share a proximal instigating stressful event
followed by intense emotional responses.

Also, a wider range of emotions
—such as rage, horror, guilt, and Click icon to add picture
shame, in addition to fear and
anxiety—may be implicated in
the onset, particularly for
posttraumatic stress disorder.

Posttraumatic Stress
Disorder (PTSD)
We have heard a great deal about the severe and long-lasting
emotional disorders that can occur after a variety of
Click ico
traumatic events.
For Americans, perhaps the most notorious traumatic events

of this century have been the wars in Iraq and Afghanistan,
the terrorist attacks on September 11, 2001, or hurricanes
(such as Hurricane Sandy in 2012).

Still, emotional disorders also occur after
physical assault (particularly rape), car
accidents, natural catastrophes, or the
sudden death of a loved one.
Posttraumatic stress disorder (PTSD) is
the best known of these disorders

Clinical Description
DSM-5 describes the setting event for PTSD as exposure to
a traumatic event during which an individual experiences or
witnesses death or threatened death, actual or threatened
serious injury, or actual or threatened sexual violation.
Learning that the traumatic event occurred to a close family

member or friend, or enduring repeated exposure to details
of a traumatic event (as in first responders to a terrorist
attack dealing with human remains) are also setting events.

Afterward, victims reexperience the event
through memories and nightmares. When
memories occur suddenly, accompanied by
strong emotion, and the victims find
themselves reliving the event, they are having a
flashback. Click icon to add picture
Victims most often avoid anything that reminds

them of the trauma. They often display a
characteristic restriction or numbing of
emotional responsiveness, which may be
disruptive to interpersonal relationships.

They are sometimes unable to remember certain aspects of the
event. It is possible that victims unconsciously attempt to
avoid the experience of emotion itself, like people with panic
disorder, because intense emotions could bring back memories
of the trauma.
Finally, victims typically are chronically over-aroused, easily

startled, and quick to anger. Click icon to add picture
New to DSM-5 is the addition of “reckless or self-destructive
behavior” under the PTSD E criteria as one sign of increased
arousal and reactivity. Also new to DSM-5 is the addition of a
“dissociative” subtype describing victims who do not
necessarily react with the reexperiencing or hyperarousal,
characteristic of PTSD.

Rather, individuals with PTSD who experience
dissociation have less arousal than normal along with
(dissociative) feelings of unreality (Wolf, Lunney, et
al., 2012; Wolf, Miller, et al., 2012.
Victims with PTSD seem to respond somewhat
differently to treatment if they meet criteria for a
dissociative subtype (Lanius, Brand, Vermetten,
Frewen, & Spiegel, 2012).

PTSD was first named in 1980 in DSM-III
(American Psychiatric Association, 1980), but it
has a long history.
In 1666, the British diarist Samuel Pepys
witnessed the Great Fire of London, which
caused substantial loss of life and property and
threw the city into chaos for a time. He captured
the events in an account that is still read today.

But Pepys did not escape the effects of the horrific
event. Six months later, he wrote, “It is strange to think
how to this very day I cannot sleep a night without
great terrors of fire; and this very night could not sleep
to almost 2 in the morning through thoughts of fire”.
The DSM-5 criteria show that difficulty sleeping and Click icon to add pic
recurring intrusive dreams of the event are prominent
features of PTSD. Pepys described his guilt at saving
himself and his property while others died. He also
experienced a sense of detachment and a numbing of
his emotions concerning the fire, common experiences
in PTSD (Keane & Miller, 2012).



EVALUATION OF THE
CASE
This case is unusual because not only did Marcie
develop PTSD, but so did her 8-year-old brother. In
addition, Cathy, 4, and Susan, 2, although quite
young, showed symptoms of the disorder, as did
their mother. Click icon to add picture
Jeff evidenced classic survivor guilt symptoms,

reporting that he should have saved Marcie or at
least put himself between Marcie and the dog. Both
Jeff and Marcie regressed developmentally, wetting
the bed (nocturnal enuresis) and experiencing
nightmares and separation fears.

Marcie, having been strapped down and given a local
anesthetic and stitches, became frightened of any
medical procedures and even of such routine daily
events as having her nails trimmed or taking a bath.
Furthermore, she refused to be tucked into bed,

something she had enjoyed all her life, probably Click icon to add picture
because it reminded her of the hospital board. Jeff
started sucking his fingers, which he had not done for
years. These behaviors, along with intense separation
anxiety, are common, particularly in younger children.

Cathy, the 4-year-old, evidenced considerable
fear and avoidance when tested but denied
having any problem when she was interviewed
by a child psychologist. Susan, the 2-year-old,
also had some symptoms, as shown in Table
5.7, but was too young to talk about them. For Click icon to add picture
several months following the trauma, however,
she repeatedly said, without provocation,
“Doggy bit sister.”

Since many individuals experience strong
reactions to stressful events that typically
disappear within a month, the diagnosis of
PTSD cannot be made until at least one
month after the occurrence of the Click icon to add picture
traumatic event. In PTSD with delayed
onset, individuals show few or no
symptoms immediately or for months after
a trauma, but at least 6 months later, and
perhaps years afterward, develop full-
blown PTSD (O’Donnell et al., 2013)
Why onset is delayed in
some individuals is not
yet clear
PTSD cannot be diagnosed until a month after the trauma. In DSM-IV a
disorder called acute stress disorder was introduced. This is similar to Clic
PTSD, occurring within the first month after the trauma, but the different
name emphasizes the severe reaction that some people have immediately.
According to a recent survey, approximately 50% of individuals with acute

stress disorder went on to develop PTSD (Bryant, 2010; Bryant, Friedman,
Spiegel, Ursano, & Strain, 2011). But these surveys also indicated that as
many as 52% of a sample of trauma survivors who went on to develop
PTSD did not meet criteria for acute stress disorder in the month following
the trauma.
Acute stress disorder was included in DSM-IV because
many people with severe early reactions to trauma
could not otherwise be diagnosed and, therefore, could
not receive insurance coverage for immediate
treatment. The surveys described above confirm that
people with early severe reactions to traumatic stress
are severely impacted and can benefit from treatment.
But these early reactions are not particularly good
predictors of who will go on to develop PTSD.

Statistics
Determining the prevalence rates for PTSD seems relatively
straightforward: Simply observe victims of a trauma and see
how many are suffering from PTSD. But a number of studies
have demonstrated the remarkably low prevalence of PTSD in Click icon to a
populations of trauma victims.
Rachman, in a classic study, reported on the British citizenry

who endured numerous life-threatening air raids during World
War II. He concluded that “a great majority of people endured
the air raids extraordinarily well, contrary to the universal
expectation of mass panic.
Exposure to repeated bombings did not produce a
significant increase in psychiatric disorders.
Although shortlived fear reactions were common,
surprisingly few persistent phobic reactions
emerged” (Rachman, 1991, p. 162). Similar results Click icon
have been observed from classic studies following
disastrous fires, earthquakes, and floods (e.g.,
Green, Grace, Lindy, Titchener, & Lindy, 1983).

Causes
PTSD is the one disorder for which we know the cause at
least in terms of the precipitating event: Someone personally
experiences trauma and develops a disorder. Whether or not a
person develops PTSD, however, is a surprisingly complex Click icon
issue involving biological, psychological, and social factors.
We know that the intensity of exposure to assaultive violence

contributes to the etiology of PTSD (Dohrenwend, Yager,
Wall, & Adams, 2012; Friedman, 2009) but does not account
for all of it.

As with other disorders, we bring our own generalized
biological and psychological vulnerabilities with us. The
greater the vulnerability, the more likely we are to develop
PTSD. If certain characteristics run in your family, you have a
much greater chance of developing the disorder. A family
history of anxiety suggests a generalized biological
vulnerability for PTSD.
Nevertheless, as with other disorders, there is little or no

evidence that genes directly cause PTSD.

While all experienced the same traumatic experience, specific characteristics
of what is referred to as the serotonin transporter gene involving two short
alleles (SS) described as increasing the probability of becoming depressed in
Chapter 2 (Caspi et al., 2003), also increased the probability of experiencing
symptoms of acute stress after the shooting, even though other factors such as
amount of exposure to the shooting were equalized (Mercer et al., 2012).
Higher intelligence predicted decreased exposure to these types of traumatic

events. That is, personality and other characteristics, some of them at least
partially heritable, may predispose people to the experience of trauma by
making it likely that they will be in (risky) situations where trauma is likely
to occur (Norrholm & Ressler, 2009).

Family instability is one factor that may instill a sense
that the world is an uncontrollable, potentially dangerous
place (Chorpita & Barlow, 1998; Suárez et al., 2009), so
it is not surprising that individuals from unstable families
are at increased risk for developing PTSD if they
experience trauma. Family instability was found to be a
pre-war risk factor for the development of PTSD in a
study of more than 1,600 male and female Vietnam
veterans.

In addition, there are certain biological individual
characteristics (biomarkers) that appear to increase the
likelihood for developing PTSD. In one study, Telch and
colleagues (Telch, Rosenfield, Lee, & Pai, 2012) asked
158 soldiers before their deployment to Iraq to inhale air
that was enriched with 35% carbon dioxide. Inhaling
such gas mixture typically leads to strong physiological
symptoms (shortness of breath, tingling, sweating, etc.)
and anxiety in some people.

Telch and colleagues found that those who reported
more emotional reactivity to the gas mixture also
experienced the war zone as much more stressful Click icon to add p
after they came back from Iraq. These soldiers were
also at greater risk for developing PTSD symptoms
and other anxiety and stress symptoms later on. This
example illustrates how certain vulnerabilities can
lead to a disorder when the person is exposed to
stressors.

Finally, social factors play a major role in the
development of PTSD (Ruzek, 2012; King et al.,
2012). The results from a number of studies are
consistent in showing that, if you have a strong and
supportive group of people around you, it is much
less likely you will develop PTSD after a trauma Click icon to ad
(Friedman, 2009).
These factors seem to be true around the world,

because the reaction to trauma is similar across
cultures, as a study comparing American and Russian
adolescents demonstrated (Ruchkin et al., 2005).
When the authors examined factors contributing to who
developed PTSD symptoms and who didn’t, social support
from parents, close friends, classmates, and teachers was an
important protective factor.
Similarly, positive coping strategies involving active

problem solving seemed to be protective, whereas becoming
angry and placing blame on others were associated with
higher levels of PTSD. The broader and deeper the network
of social support, the less the chance of developing PTSD.

TREATMENT
From the psychological point of view, most clinicians
agree that victims of PTSD should face the original
trauma, process the intense emotions, and develop Click icon to add picture
effective coping procedures in order to overcome the
debilitating effects of the disorder (Beck & Sloan, 2012;
Najavits, 2007; Monson, Resick, & Rizvi, 2014).
In psychoanalytic therapy, reliving emotional trauma to

relieve emotional suffering is called catharsis. The trick is
in arranging the preexposure so that it will be therapeutic
rather than traumatic.
The trick is in arranging the reexposure so that it
will be therapeutic rather than traumatic. Unlike
the object of a specific phobia, a traumatic event is
difficult to recreate, and few therapists want to try.
Imaginal exposure, in which the content of the Click icon to ad

trauma and the emotions associated with it are
worked through systematically, has been used for
decades under a variety of names.

At present, the most common strategy to achieve this purpose with
adolescents or adults is to work with the victim to develop a narrative of
the traumatic experience and to expose the patients for an extended
period of time to the image (prolonged exposure therapy) that is then
reviewed extensively in treatment.
Patients in the study were asked to take a nap soon after an exposure
because extinction learning appears to take place during slow-wave sleep
and also because sleep quality reduces anxiety.

Cognitive therapy to correct negative assumptions about the
trauma—such as blaming oneself in some way, feeling guilty,
or both—is another part of treatment (Ehlers et al., 2014;
Najavits, 2007; Monson et al., 2014).
Another complication is that trauma victims often repress the

emotional side of their memories of the event and sometimes,
it seems, the memory itself.

Occasionally, with treatment, the memories flood back and the
patient dramatically relives the episode. Although this may be
frightening to both patient and therapist, it can be therapeutic if
handled appropriately.
Evidence is now accumulating that early, structured interventions

delivered as soon after the trauma as possible to those who require
help are useful in preventing the development of PTSD.

Obsessive-Compulsive
and Related Disorders
Another new class of disorders in DSM-5 brings together several
disorders that share a number of characteristics, such as driven
repetitive behaviors and some other symptoms, and a similar course
and treatment response (Abramowitz & Jacoby, 2015). Click icon to add
Previously these disorders had been scattered in other areas of DSM-
IV. In addition to obsessive-compulsive disorder, which has been
classified as an anxiety disorder until DSM-5, this grouping now
includes a separate diagnostic category for hoarding disorder, body
dysmorphic disorder previously located with the somatoform disorders,
and trichotillomania previously grouped with the impulse control
disorders.

Also, another new disorder in this group is
excoriation (skin picking) disorder. We begin
with the most prominent disorder in this group,
obsessive-compulsive disorder.

Obsessive-Compulsive
Disorder
Among the persons suffering from anxiety and related disorders, a client who needs
hospitalization is likely to have obsessivecompulsive disorder (OCD). A client referred
for psychosurgery (neurosurgery for a psychological disorder) because every
psychological and pharmacological treatment has failed, and the suffering is unbearable,
probably has OCD. Click icon to a
OCD is the devastating culmination of the anxiety disorders. It is not uncommon for
someone with OCD to experience severe generalized anxiety, recurrent panic attacks,
debilitating avoidance, and major depression, all occurring simultaneously with
obsessive-compulsive symptoms.
With OCD, establishing even a foothold of control and predictability over the dangerous
events in life seems so utterly hopeless that victims resort to magic and rituals.

Clinical Description
In other anxiety disorders, the danger is usually in an
external object or situation, or at least in the memory
of one. Click icon to add picture
In OCD, the dangerous event is a thought, image, or
impulse that the client attempts to avoid as
completely as someone with a snake phobia avoids
snakes (Clark & O’Connor, 2005).

For example, has anyone ever told you not to think
of pink elephants? If you really concentrate on not
thinking of pink elephants, using every mental
means possible, you will realize how difficult it is
to suppress a suggested thought or image.
Obsessions are intrusive and mostly nonsensical

thoughts, images, or urges that the individual tries
to resist or eliminate. Compulsions are the
thoughts or actions used to suppress the
obsessions and provide relief.


Types of Obsessions and
Compulsions
Based on statistically associated groupings,
there are four major types of obsessions:
Each is associated with a pattern of
compulsive behavior.
“Symmetry obsessions” account for most

obsessions “forbidden thoughts or actions”,
“cleaning and contamination”, and hoarding.


Symmetry refers to
keeping things in perfect order or doing something in a specific way.
a. As a child, were you careful not to step on cracks in the sidewalk You and your
friends might have kept this up for a few minutes before tiring of it. But what if you
had to spend your whole life avoiding cracks, on foot or in a car, to prevent something Click
bad from happening? You wouldn’t have much fun.
b. People with aggressive (forbidden) obsessive impulses may feel they are about to
yell out a swear word in church. A young and moral woman, was afraid to ride the bus
for fear that if a man sat down beside her she would grab his crotch! In reality, this
would be the last thing she would do, but the aggressive urge was so horrifying that
she made every attempt possible to suppress it and to avoid riding the bus or similar
situations where the impulse might occur.

Certain kinds of obsessions are strongly associated with certain kinds of
rituals.
Checking rituals serve to prevent an imagined disaster or catastrophe.

Click icon
Many are logical, such as repeatedly checking the stove to see whether you
turned it off, but severe cases can be illogical.
Obsessions with symmetry lead to ordering and arranging or repeating

rituals; obsessions with contamination lead to washing rituals that may
restore a sense of safety and control.

On rare occasions, patients, particularly
children, will present with compulsions, but
few or no identifiable obsessions.
Example:
an 8-year-old child who felt compelled to
undress, put on his pajamas, and turn down the
covers in a time-consuming fashion each night;
he always repeated the ritual three times. He
could give no particular reason for his
behavior; he simply had to do it.

Tic Disorder and OCD
It is also common for tic disorder, characterized
by involuntary movement (sudden jerking of
limbs, for example), to co-occur in patients
with OCD (particularly children) or in their
families.
More complex tics with involuntary
vocalizations are referred to as Tourette’s
disorder. n some cases, these movements are
not tics but may be compulsions. The
obsessions in tic-related OCD are almost
always related to symmetry. CBT has been
found to be quite effective for treating tic
disorders (McGuire et al., 2015).

Observations among one small group of children presenting with OCD and tics
suggest that these problems occurred after a bout of strep throat. This syndrome
has been referred to as pediatric autoimmune disorder associated with
streptococcal infection, or “PANDAS” (Leckman et al., 2010; Radomsky &
Taylor, 2005)
Presentation of OCD in these cases differs somewhat from OCD without a

history of “PANDAS” in several ways. The PANDAS group is more likely to be
male; experience dramatic onset of symptoms often associated with fever or sore
throat; have full remissions between episodes; show remission of symptoms
during antibiotic therapy; have evidence of past streptococcal infections; and
present with noticeable clumsiness (Murphy, Storch, Lewin, Edge, & Goodman,
2012).

Statistics
Obsessions and compulsions can be arranged
along a continuum, like most clinical features
of anxiety disorders. Intrusive and distressing
thoughts are common in nonclinical (“normal”)
individuals.
Spinella (2005) found that 13% of a “normal”
community sample of people had moderate
levels of obsessions or compulsions that were
not severe enough to meet diagnostic criteria
for OCD.

It would also be unusual not to have an
occasional intrusive or strange thought. Many
people have bizarre, sexual, or aggressive
thoughts, particularly if they are bored—for
example, when sitting in class. Steketee and
Barlow (2002) collected examples of thoughts
from ordinary people who do not have OCD.

Certain individuals, however, are horrified by
such thoughts, considering them signs of an
alien, intrusive, evil force.
Unlike other anxiety and related disorders,

OCD has a ratio of female to male that is
nearly 1:1.
Although there is some evidence in children

that there are more males than females (Hanna,
1995), this seems to be because boys tend to
develop OCD earlier. By mid-adolescence, the
sex ratio is approximately equal (Albano et al.,
1996).

Age of onset ranges from childhood through the 30s,
with a median age of onset of 19 (Kessler, Berglund,
Demler, et al., 2005). The age of onset peaks earlier
in males (13 to 15) than in females (20 to 24)
(Rasmussen & Eisen, 1990). Once OCD develops, it Click icon to add picture
tends to become chronic (Calamari et al., 2012;
Steketee & Barlow, 2002).
In Arabic countries, OCD is easily recognizable,

although as always cultural beliefs and concerns
influence the content of the obsessions and the
nature of the compulsions. In Saudi Arabia and
Egypt, obsessions are primarily related to religious
practices, specifically the Muslim emphasis on
cleanliness. Contamination themes are also highly
prevalent in India.

Nevertheless, OCD looks remarkably similar
across cultures. Studies from England, Hong
Kong, India, Egypt, Japan, and Norway found
essentially similar types and proportions of
obsessions and compulsions, as did studies
from Canada, Finland, Taiwan, Africa, Puerto
Rico, Korea, and New Zealand.

Causes
Many of us sometimes have intrusive, even
horrific, thoughts and occasionally engage in
ritualistic behavior, especially when we are
under stress.
But few of us develop OCD. Again, as with
panic disorder and PTSD, someone must
develop anxiety focused on the possibility of
having additional intrusive thoughts.

Thought–action fusion may, in turn, be caused by attitudes of excessive
responsibility and resulting guilt developed during childhood, when even
a bad thought is associated with evil intent (Clark & O’Connor, 2005;
Steketee & Barlow, 2002; Taylor, Abramowitz, McKay, & Cuttler, 2012).
They may learn this through the same process of misinformation that
convinced the person with snake phobia that snakes were dangerous and
could be everywhere

Example:
One patient believed thinking about abortion was
the moral equivalent of having an abortion.
Richard finally admitted to having strong Click icon to add picture
homosexual impulses that were unacceptable to
him and to his minister father, and he believed the
impulses were as sinful as actual acts.

Many people with OCD who believe in the
tenets of fundamental religions, whether
Christian, Jewish, or Islamic, present with
similar attitudes of inflated responsibility and
thought–action fusion. Several studies showed
that the strength of religious belief, but not the
type of belief, was associated with thought–
action fusion and severity of OCD.

Of course, most people with fundamental religious beliefs do not develop OCD. But
what if the most frightening thing in your life was not a snake or speaking in public, but
a terrible thought that happened to pop into your head? You can’t avoid it as you would
a snake, so you resist this thought by attempting to suppress it or “neutralize” it using
mental or behavioral strategies, such as distraction, praying, or checking. These
strategies become compulsions, but they are doomed to fail in the long term, because
these strategies backfire and actually increase the frequency of the thought (Franklin &
Foa, 2014; Wegner, 1989).

Again, generalized biological and psychological
vulnerabilities must be present for this disorder to
develop. Believing some thoughts are unacceptable Click icon to add picture
and therefore must be suppressed (a specific
psychological vulnerability) may put people at
greater risk of OCD (Parkinson & Rachman, 1981b;
Salkovskis & Campbell, 1994).

Treatment
The effects of drugs on OCD have been evaluated
extensively (Dougherty, Rauch, & Jenike, 2012; Stewart,
Jenike, & Jenike, 2009). The most effective seems to be Click icon to add picture
those that specifically inhibit the reuptake of serotonin,
such as clomipramine or SSRIs, which benefit up to 60%
of patients with OCD, with no particular advantage to
one drug over another.
Highly structured psychological treatments work

somewhat better than drugs, but they are not readily
available.
The most effective approach is called exposure and ritual prevention (ERP), a process
whereby the rituals are actively prevented and the patient is systematically and gradually
exposed to the feared thoughts or situations.
Studies have evaluated the combined effects of medication and psychological treatments
(Romanelli, Wu, Gamba, Mojtabai, & Segal, 2014; Simpson et al., 2013; Tolin, 2011). In
one large study (Foa et al., 2005), ERP was compared with the drug clomipramine, as well
as with a combined condition. ERP, with or without the drug, produced superior results to
the drug alone, with 86% responding to ERP alone versus 48% to the drug alone

Combining the treatments did not produce any additional
advantage. Also, relapse rates were high from the medication-
only group when the drug was withdrawn. Furthermore,
medication such as SSRIs appear to be only effective in a
subgroup of patients, possibly because these drugs primarily
dampen the symptoms but do not correct the dysregulated
neural circuits (Ressler & Rothbaum, 2013). Therefore, adding
ERP to people who continue to have OCD symptoms after
starting an SSRI can be more beneficial than adding another
medication (Simpson et al., 2013)
Psychosurgery is one of the more radical treatments
for OCD. “Psychosurgery” is a misnomer that
refers to neurosurgery for a psychological disorder. Click icon to add picture
The advantage of deep brain stimulation over more
traditional surgery is that it is reversible
(McLaughlin & Greenberg, 2012). Considering that
these patients seemed to have no hope from other
treatments, surgery deserves consideration as a last
resort.

Body Dysmorphic
Disorder
Did you ever wish you could change part of
your appearance? Maybe the size of your nose
or the way your ears stick out? Most people
fantasize about improving something, but some
relatively normal-looking people think they are
so ugly they refuse to interact with others or
otherwise function normally for fear that
people will laugh at their ugliness.
at its center is a preoccupation with some

imagined defect in appearance by someone
who actually looks reasonably normal. The
disorder is referred to as “imagined ugliness.”


For many years, BDD was considered a somatoform disorder because its
central feature is a psychological preoccupation with somatic (physical)
issues. But increasing evidence indicated it was more closely related to
OCD, accounting for its relocation to the obsessive-compulsive and related
disorders section in DSM-5.
For example, OCD often co-occurs with BDD and is found among family
members of BDD patients.

There are other similarities. People with BDD complain of persistent,
intrusive, and horrible thoughts about their appearance, and they engage in
such compulsive behaviors as repeatedly looking in mirrors to check their
physical features. BDD and OCD also have approximately the same age of
onset and run the same course. One brain-imaging study demonstrated
similar abnormal brain functioning between patients with BDD and
patients with OCD.

A variety of checking or compensating rituals are common in people
with BDD in attempts to alleviate their concerns.
For example, excessive tanning is common, with 25% of one group of

200 patients tanning themselves in an attempt to hide skin defects
(Phillips, Menard, Fay, & Weisberg, 2005). Excessive grooming and
skin picking are also common.
Many people with this disorder become fixated on mirrors (Veale &
Riley, 2001). They often check their presumed ugly feature 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 is typical consequences
of this disorder.
People with BDD also have “ideas of reference,” which means they think
everything that goes on in their world somehow is related to them—in this
case, to their imagined defect. This disorder can cause considerable
disruption in the patient’s life. Many patients with severe cases become
housebound for fear of showing themselves to other people.

If this disorder seems strange to you, you are not
alone. For decades, this condition, previously known
as dysmorphophobia (literally, fear of ugliness), was
thought to represent a psychotic delusional state
because the affected individuals were unable to
realize, even for a fleeting moment, that their ideas
were irrational.

The prevalence of BDD is hard to estimate because by its very nature it
tends to be kept secret. The best estimates, however, are that it is far more
common than we had previously thought. Without some sort of treatment,
it tends to run a lifelong course (Phillips, 1991; Veale, Boocock, et al.,
1996).
In mental health clinics, the disorder is also uncommon because most

people with BDD seek other types of health professionals, such as plastic
surgeons and dermatologists. BDD is seen equally in men and women

In the larger series of 200 individuals reported by Phillips, Menard, Fay,
and Weisberg (2005), 68.5% were female, but 62% of a large number of
individuals with BDD in Japan were males.
Men tend to focus on body build, genitals, and thinning hair and tend to
have more severe BDD. A focus on muscle defects and body building is
nearly unique to men with the disorder (Pope et al., 2005). Women focus
on more varied body areas and are more likely to also have an eating
disorder.

Individuals are somewhat reluctant to seek treatment. In
many cases, a relative will force the issue, demanding the
individual get help; this insistence may reflect the
disruptiveness of the disorder for family members.
BDD is among the more serious of psychological disorders,

and depression and substance abuse are common
consequences of BDD.

As you might suspect, few people with this disorder get married.
Further reflecting the intense suffering that accompanies this
disorder, Veale (2000) collected information on 25 patients with
BDD who had sought cosmetic surgery in the past.
Individuals with BDD react to what they think is a horrible or

grotesque feature. Thus, the psychopathology lies in their
reacting to a “deformity” that others cannot perceive. Social and
cultural determinants of beauty and body image largely define
what is “deformed.

The behavior of individuals with BDD seems remarkably strange because
they go against current cultural practices that put less emphasis on
altering facial features. In other words, people who simply conform to the
expectations of their culture do not have a disorder.
Nevertheless, aesthetic plastic surgery, particularly for the nose and lips,
is still widely accepted and, because it is most often undertaken by the
wealthy, carries an aura of elevated status.
In this light, BDD may not be so strange. As with most psychopathology,

its characteristic attitudes and behavior may simply be an exaggeration of
normal culturally sanctioned behavior

We know little about the etiology of BDD specifically. There is
almost no information on whether it runs in families, so we can’t
investigate a specific genetic contribution. Similarly, there is no
meaningful information on biological or psychological
predisposing factors or vulnerabilities. Psychoanalytic
speculations are numerous, but most center on the defensive
mechanism of displacement—that is, an underlying unconscious
conflict would be too anxiety provoking to admit into
consciousness, so the person displaces it onto a body part.

What little evidence we do have on etiology comes from the pattern
of comorbidity of BDD with OCD described earlier. The marked
similarities to OCD suggest, perhaps, somewhat similar patterns of
etiology.
Another interesting lead on causes of BDD comes from cross -

cultural explorations of similar disorders. Patients who would be
diagnosed with BDD in our culture might simply be considered to
have severe social anxiety in Japan and Korea. Possibly, then, social
anxiety is fundamentally related to BDD, a connection that would
give us further hints on the nature of the disorder.

A recent study of BDD in Western countries
indicates that concerns relating to perceived
negative evaluation of their appearance by others
is every bit as important as self-evaluation of the
imagined defects in appearance (Anson, Veale, &
de Silva, 2012). Studies of comorbidity indicate
that social anxiety disorder, along with OCD, is
also commonly found in people with BDD (Fang
& Hofmann, 2010; Phillips & Stout, 2006).

Somatic Symptom and Related
Disorders and Dissociative
Disorders

Do you know somebody
who’s a hypochondriac?
M
The popular image of this condition, now
called more accurately “illness anxiety
disorder” in the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders
(DSM-5) (American Psychiatric Association,
2013

Hypochondriasis
is of someone who exaggerates the slightest physical
symptom. Many people continually run to the doctor
even though there is nothing really wrong with them.
This is usually a harmless tendency that may even be
worth some good-natured jokes. But for a few
individuals, the preoccupation with their health or
appearance becomes so great that it dominates their
lives.

Their problems fall under the general heading of somatic
symptom disorders. Soma means body, and the problems
preoccupying these people seem, initially, to be physical
disorders.
What the somatic symptom disorders have in common is that

there is an excessive or maladaptive response to physical
symptoms or to associated health concerns. These disorders are
sometimes grouped under the shorthand label of “medically
unexplained physical symptoms”

In some cases the medical cause of
the presenting physical symptoms is Click icon to add picture
known but the emotional distress or
level of impairment in response to this
symptom is clearly excessive and may
even make the condition worse.

Dissociation and
Dissociative Experiences
Have you ever felt “detached” from
yourself or your surroundings? (“This Click icon to add picture
isn’t really me,” or “That doesn’t
really look like my hand,” or
“There’s something unreal about this
place.”)

During these experiences, some people feel as if they are
dreaming. These mild sensations that most people
experience occasionally are slight alterations, or
detachments, in consciousness or identity.
For a few people, these experiences are so intense and

extreme that they lose their identity entirely and assume a
new one, or they lose their memory or sense of reality and
are unable to function.
Somatic symptom and dissociative disorders are strongly linked historically,
and evidence indicates they share common features (Kihlstrom, Glisky, &
Anguilo, 1994; Prelior, Yutzy, Dean, & Wetzel, 1993).
They used to be categorized under one general heading, “hysterical

neurosis.”
the term hysteria—which dates back to the Greek physician Hippocrates, and
the Egyptians before him—suggests that the cause of these disorders, which
were thought to occur primarily in women, can be traced to a “wandering
uterus”.
But the term hysterical came to refer more generally to physical
symptoms without known organic cause or to dramatic or
“histrionic” behavior thought to be characteristic of women.
Sigmund Freud (1894–1962) suggested that in a condition called

conversion hysteria, unexplained physical symptoms indicated the
conversion of unconscious emotional conflicts into a more
acceptable form. The historical term conversion remains with us
(without the theoretical implications); however, the prejudicial
and stigmatizing term hysterical is no longer used.

The term neurosis, as defined in psychoanalytic theory,
suggested a specific cause for certain disorders. Specifically,
neurotic disorders resulted from underlying unconscious
conflicts, anxiety that resulted from those conflicts, and the
implementation of ego defense mechanisms.
Neurosis was eliminated from the diagnostic system in 1980

because it was too vague, applying to almost all nonpsychotic
disorders, and because it implied a specific but unproven cause
for these disorders.

Somatic symptom disorders and dissociative disorders are
not well understood, but they have intrigued
psychopathologists and the public for centuries.
A fuller understanding provides a rich perspective on the
extent to which normal, everyday traits found in all of us can
evolve into distorted, strange, and incapacitating disorders.

Somatic Symptom
Disorder
In 1859, Pierre Briquet, a French physician, described patients who came to see him with
seemingly endless lists of somatic complaints for which he could find no medical basis
(American Psychiatric Association, 1980).
Despite his negative findings, patients returned shortly with either the same complaints or
new lists containing slight variations. For many years, this disorder was called Briquet’s
syndrome, but now would be considered somatic symptom disorder.
the important factor in this condition is not whether the physical symptom, in this case
pain, has a clear medical cause or not, but rather that psychological or behavioral factors,
particularly anxiety and distress, are compounding the severity and impairment
associated with the physical symptoms.

The new emphasis in DSM-5 on the psychological symptoms in
these disorders is useful to clinicians since it highlights the
psychological experiences of anxiety and distress focused on the
somatic symptoms as the most important target for treatment
(Tomenson et al., 2012; Voigt et al., 2012). But an important
feature of these physical symptoms, such as pain, is that it is real
and it hurts whether there are clear physical reasons for pain or
not.

Illness Anxiety Disorder
was formerly known as “hypochondriasis,” which is still the
term widely used among the public. In illness anxiety disorder
as we know it today, physical symptoms are either not
experienced at the present time or are very mild, but severe
anxiety is focused on the possibility of having or developing a
serious disease. If one or more physical symptoms are
relatively severe and are associated with anxiety and distress,
the diagnosis would be somatic symptom disorder.

Using DSM-5 criteria, only about 20% of patients who used to meet the
diagnostic criteria for DSM IV hypochondriasis now meet criteria for
illness anxiety disorder, in part because they do not complain about
having any somatic symptoms at all despite experiencing serious anxiety
about contracting an illness (Rief & Martin, 2014).
In illness anxiety disorder the concern is primarily with the idea of being
sick instead of the physical symptom itself. And the threat seems so real
that reassurance from physicians does not seem to help.

Research indicates that illness anxiety disorder and somatic symptom disorder
share many features with the anxiety and mood disorders, particularly panic
disorder (Craske et al., 1996; Creed & Barsky, 2004), including similar age of
onset, personality characteristics, and patterns of familial aggregation (running
in families). Indeed, anxiety and mood disorders are often comorbid with
somatic symptom disorders; that is, if individuals with somatic symptom
disorders have additional diagnoses, these most likely are anxiety or mood
disorders.

Illness anxiety disorder is characterized by anxiety or fear
that one has a serious disease. Therefore, the essential
problem is anxiety, but its expression is different from
that of the other anxiety disorders. In illness anxiety
disorder, the individual is preoccupied with bodily
symptoms, misinterpreting them as indicative of illness or
disease.

In illness anxiety disorder, the individual is preoccupied with
bodily symptoms, misinterpreting them as indicative of illness or
disease. Almost any physical sensation may become the basis for
concern. Some may focus on normal bodily functions such as
heart rate or perspiration, others on minor physical abnormalities
such as a cough. Some individuals complain of vague symptoms,
such as aches or fatigue. Because a key feature of this disorder is
preoccupation with physical symptoms, individuals with these
disorders almost always go initially to family physicians.

They come to the attention of mental health professionals only after family
physicians have ruled out realistic medical conditions as a cause of the
patient’s symptoms.
Finally, the anxieties of individuals with panic disorder tend to focus on the
specific set of 10 or 15 sympathetic nervous system symptoms associated
with a panic attack. Concerns range much wider in somatic symptom
disorders. Nevertheless, there are probably more similarities than
differences between these groups.

Statistics
We can only estimate prevalence of somatic symptom disorders in the general
population, mostly from studies of similar DSM-IV disorders that were defined
a bit differently than the current DSM-5 disorders.
For example, the prevalence of DSM-IV hypochondriasis, which would

encompass illness anxiety disorder and part of somatic symptom disorder, has
been estimated to be from 1% to 5% (American Psychiatric Association, 2000).
In primary care settings, the median prevalence rate for hypochondriasis is
6.7% but as high as 16.6% for distressing somatic symptoms, which should
closely approximate the prevalence of somatic symptom disorder and illness
anxiety disorder combined in these settings (Creed & Barsky, 2004).

Severe illness anxiety has a late age of onset, possibly because more
physical health problems occur with aging (El-Gabalawy, Mackenzie,
Thibodeau, Asmundson, & Sareen, 2013).
In addition to a variety of somatic complaints, individuals may have

psychological complaints, usually anxiety or mood disorders (Simms,
Prisciandaro, Krueger, & Goldberg, 2012; Rief et al., 1998). Patients with
these disorders who happened to be in psychiatric clinics reported
seemingly endless psychological complaints, including psychotic
symptoms, in addition to their physical complaints.

Suicidal attempts that appear to be manipulative gestures rather
than true death efforts are frequent (Chioqueta & Stiles, 2004).
Obviously, individuals with somatic symptom disorders overuse
and misuse the health-care system, with medical bills as much as 9
times more than the average patient (Barsky, Orav, & Bates, 2005;
Hiller, Fichter, & Rief, 2003; Woolfolk & Allen, 2011).
Although symptoms may come and go, somatic symptom

disorders and the accompanying sick role behavior are chronic,
often continuing into old age.



quarterly performance
Q1
Q2
Q3
Q4
- 1.0 2.0 3.0 4.0 5.0 6.0
Series 1 Series 2

areas of growth
B2B SUPPLY CHAIN ROI E-COMMERCE
Q1 4.5 2.3 1.7 5.0
Q2 3.2 5.1 4.4 3.0
Q3 2.1 1.7 2.5 2.8
Q4 4.5 2.2 1.7 7.0

RICHARD BRANSON
“Business opportunities are like buses.

There's always another one coming.”

meet our team
TAKUMA HAYASHI MIRJAM NILSSON FLORA BERGGREN RAJESH SANTOSHI

president chief executive officer chief operations officer vp marketing

meet our extended team
TAKUMA HAYASHI MIRJAM NILSSON FLORA BERGGREN RAJESH SANTOSHI

president chief executive officer chief operations officer vp marketing
GRAHAM BARNES ROWAN MURPHY ELIZABETH MOORE ROBINE KLINE

vp product SEO strategist product designer content developer
plan for product launch
PLANNING synergize scalable e-commerce
MARKETING disseminate standardized metrics
DESIGN coordinate e-business applications
STRATEGY foster holistically superior methodologies
LAUNCH deploy strategic networks with compelling e-business needs

timeline
NOV 20XX
disseminate standardized metrics
SEP 20XX
synergize scalable e-commerce
JAN 20XX
coordinate e-business applications
MAR 20XX MAY 20XX

foster holistically superior deploy strategic networks with
methodologies compelling e-business needs
areas of focus
B2B MARKET SCENARIOS
o Develop winning strategies to keep ahead of the competition
o Capitalize on low-hanging fruit to identify a ballpark value
o Visualize customer directed convergence
CLOUD-BASED OPPORTUNITIES
o Iterative approaches to corporate strategy
o Establish a management framework from the inside

how we get there
ROI NICHE MARKETS SUPPLY CHAINS
o Envision multimedia- o Pursue scalable customer o Cultivate one-to-one

based expertise and cross- service through customer service with
media growth strategies sustainable strategies robust ideas
o Visualize quality o Engage top-line web o Maximize timely

intellectual capital services with cutting-edge deliverables for real-time
deliverables schemas
o Engage worldwide
methodologies with web-
enabled technologies

summary
At Contoso, we believe in giving 110%. By
using our next-generation data architecture, we
help organizations virtually manage
agile workflows. We thrive because of our
market knowledge and great team behind our
product. As our CEO says, "Efficiencies will
come from proactively transforming how we
do business."

thank you
mirjam nilsson
mirjam@contoso.com
www.contoso.com

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Trauma and Stressor-Related

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For Americans, perhaps the most notorious traumatic events

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Learning that the traumatic event occurred to a close family

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Victims most often avoid anything that reminds

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Finally, victims typically are chronically over-aroused, easily

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Jeff evidenced classic survivor guilt symptoms,

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Furthermore, she refused to be tucked into bed,

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According to a recent survey, approximately 50% of individuals with acute

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Rachman, in a classic study, reported on the British citizenry

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We know that the intensity of exposure to assaultive violence

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Nevertheless, as with other disorders, there is little or no

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Higher intelligence predicted decreased exposure to these types of traumatic

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These factors seem to be true around the world,

Similarly, positive coping strategies involving active

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In psychoanalytic therapy, reliving emotional trauma to

Imaginal exposure, in which the content of the Click icon to ad

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Another complication is that trauma victims often repress the

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Evidence is now accumulating that early, structured interventions

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Obsessions are intrusive and mostly nonsensical

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“Symmetry obsessions” account for most

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