chapter 7 acute and posttraumatic stress disorders ... · the individual has three (or more) of the...

Chapter 7Acute and Posttraumatic Stress

Disorders, Dissociative Disorders, and Somatoform Disorders

Copyright © 2006 Pearson Education Canada Inc.

Copyright © 2006 Pearson Education Canada Inc. 2

Overview

� Focus: normal vs. pathological reactions to

trauma

� Anyone might develop a stress/trauma

related disorder given the critical level of

exposure

� Dissociation – disruption of the normally

integrated processes of memory

consciousness, identity, or perception


Definition of Trauma

A unique individual experience, associated with an

event or enduring condition, in which:

- the individual’s ability to integrate affective

experience is overwhelmed or

- the individual experiences a threat to life or bodily

integrity L.A. Pearlman and K. Saakvitne


DSM IV-TR: Defining Trauma

� event: actual/threatened death or

serious injury to self or others

� response: intense fear, helplessness, &

horror

�emphasizes subjective response


Types of Trauma

- Sexual Abuse

- Physical Abuse

- War related

- Terminal illness

- Gang Violence

- Natural Disaster


Characterological Impacts

– Damaged sense of control

– Anxiety Dysregulation

– Repression

– Shame/Guilt

– Erosion of Trust


Acute and Posttraumatic Stress Disorders

� Stress: normal aspect of everyday life

(Ch. 8)

� Traumatic stress:

– event that involves actual or threatened

death/serious injury to self or others

– Creates intense feelings of fear or horror


Acute stress disorder (ASD)

– The person has been exposed to a traumatic event in

which both of the following were present:

� the person experienced, witnessed, or was confronted

with an event or events that involved actual or

threatened death or serious injury, or a threat to the physical integrity of self or others

� the person's response involved intense fear,

helplessness, or horror

� within 4 weeks after exposure - the disturbance lasts

for a minimum of 2 days and a maximum of 4 weeks



– Either while experiencing or after experiencing the distressing event,

the individual has three (or more) of the following dissociative

symptoms:

� a subjective sense of numbing, detachment, or absence of

emotional responsiveness

� a reduction in awareness of his or her surroundings (e.g., "being in

a daze")

� derealization

� depersonalization

� dissociative amnesia (i.e., inability to recall an important aspect of

the trauma)



– The traumatic event is persistently reexperienced in at least one of

the following ways: recurrent images, thoughts, dreams, illusions,

flashback episodes, or a sense of reliving the experience; or distress

on exposure to reminders of the traumatic event.

– Marked avoidance of stimuli that arouse recollections of the trauma

(e.g., thoughts, feelings, conversations, activities, places, people).

– Marked symptoms of anxiety or increased arousal (e.g., difficulty

sleeping, irritability, poor concentration, hypervigilance, exaggerated

startle response, motor restlessness).


Posttraumatic stress disorder (PTSD)

� like ASD, characterized by

– dissociative symptoms

– re-experiencing of the event

– marked anxiety/arousal

� Unlike ASD, symptoms long-lasting

� More than 1 month

� Lifetime Prevalence is 11%



� The traumatic event is persistently reexperienced in one (or

more) of the following ways:

– recurrent and distressing recollections of the event (e.g., images or

thoughts).

– recurrent distressing dreams of the event.

– acting or feeling as if the traumatic event were recurring (e.g., includes a

sense of reliving the experience, illusions, hallucinations).

– intense psychological distress at exposure to internal or external cues

that symbolize or resemble an aspect of the traumatic event

– physiological reactivity on exposure to internal or external cues that

symbolize or resemble an aspect of the traumatic event



� Persistent avoidance of stimuli associated with the trauma and numbing

of general responsiveness (not present before the trauma), as indicated

by three (or more) of the following:

– avoids thoughts, feelings, or conversations associated with the trauma

– avoids activities, places, or people that arouse recollections of the trauma

– inability to recall an important aspect of the trauma

– markedly diminished interest or participation in significant activities

– feeling of detachment or estrangement from others

– restricted range of affect (e.g., unable to have loving feelings)

– sense of a foreshortened future (e.g., does not expect to have a career,

marriage, children, or a normal life span)



� Persistent symptoms of increased arousal (not

present before the trauma), as indicated by two (or

more) of the following:

– difficulty falling or staying asleep

– irritability or outbursts of anger

– difficulty concentrating

– hypervigilance

– exaggerated startle response


ASD & PTSD: Typical Symptoms

1. Re-experiencing trauma

2. Avoidance of associated stimuli

3. Persistent arousal/anxiety

4. Survivors guilt

� ASD not PTSD: dissociative symptoms


1. Re-experiencing Trauma

� Persistent, horrific images (e.g.,

nightmares)

� Flashbacks – spontaneous memories

of trauma


2. Avoidance

� thoughts or feelings about the event

� associated people, places, or

activities

� numbing of responsiveness


3. Arousal/Anxiety

� hypervigilance

� sleep/concentration difficulties

� irritability

� heightened startle response


Historical Perspective

� “combat neurosis”

� “shell shock”

� interest in PTSD amplifies following

Vietnam War


Etiology

� Social factors

– level of exposure

– post-trauma social support

� Psychological factors

– two-factor theory

– Classical and Operant conditioning


Prevention/Treatment

� prevention through early intervention

� critical incident stress debriefing

(CISD)

� anti-depressants (but not anxiolytics)

� CBT

� exposure therapy

� EMDR


Dissociative Disorders

� persistent problems in the integration

of memory, consciousness, or identity

� perhaps best interpreted from a

psychoanalytic perspective

– Unconscious processes


Dissociative Identity Disorder (DID)

– formally called Multiple Personality Disorder

– 2+ personalities in the same individual

– personalities are very different in nature, often representing

extremes of what is contained in a normal person.

– At least two of these personalities repeatedly assume control

of the patient's behavior.

– Common forgetfulness cannot explain the patient's extensive

inability to remember important personal information.

– This behavior is not directly caused by substance use (such

as alcoholic blackouts) or by a general medical condition.


Depersonalization Disorder

� A feeling of detachment from, or being an outside observer of,

one's mental processes or body occurs such as the sensation

of being in a dream. This phenomena involves:

� A lasting or recurring feeling of being detached from the

patient's own body.

� Throughout the experience, the patient knows this is not really

the case. Reality experience is intact.

� The disorder is not directly caused by a general medical

condition or by substance use, including medications and

drugs of abuse.


Dissociative Amnesia

� The predominant disturbance is one or more

episodes of inability to recall important personal

information, usually of a traumatic or stressful

nature, that is too extensive to be explained by

ordinary forgetfulness.


Dissociative Amnesia

� Selective Amnesia: a person can recall only small parts of events (e.g., victim may recall only some parts of the series of events around his or her abuse.

� Generalised Amnesia: is diagnosed when a person's amnesia encompasses this entire life.

� Continuous Amnesia: occurs when the individual has no memory for events

beginning from a certain point in the past continuing up to the present.

� Systematised Amnesia: is characterised by a loss of memory for a specific

category of information. A person with this disorder might, for example, be missing all memories about one specific family member.

� Dissociative Fugue: a person suddenly and unexpectedly takes physical leave

of his surroundings and sets off on a journey of some kind. These journeys can last hours, days or months and can cover thousands of miles. In some cases

will assume a new identity


DID Controversies

� problem of self-report

� reliability of recovered memories– infantile amnesia

– scientific evidence for false memories


Skepticism regarding DID

� most diagnoses by a small number of advocates

� increased diagnoses following release of Sybil

� increasing number of personalities in DID cases

(1980 = 200; 1986 = 6000)

� why only in North America?


Etiology

� Psychological factors– recurring childhood trauma - evaluation of the past

from the vantage point of the present

– self-hypnosis

– state dependant learning

� Biological factors– genetic (conflicting research findings)

– Preliminary evidence indicates no genetic contribution

� Social factors– Social role theory


Spanos’ Theory of DID

� not a true “disorder”

� patients are role-playing– symptoms are iatrogenic

– patients develop multiple personalities in response

to the leading questions of therapists, not as a result

of a defense mechanism.


Treatment of Dissociative Disorders

� Psychological approach

– recovery of traumatic memories� hypnosis

– main objective: integration of personalities

� Medical approach

– distress reduction


Somatoform Disorders

�Problems featuring physical symptoms with no organic basis

�perhaps best interpreted from a psychoanalytic perspective

– symptoms not faked

– unconscious factors


Typical Symptoms: 3 Variations

� single impairment of somatic system

(e.g., paralysis, blindness)

� multiple physical symptoms (e.g., pain

& gastrointestinal symptoms)

� Preoccupation with a single disease

(e.g., cancer)


5 types of somatoform disorders

1) Conversion Disorder

� psychological conflicts converted into physical symptoms

� symptoms mimic common neurological conditions

� often inconsistent with accurate anatomical functioning -

therefore, not a medical condition

� Conflicts or other stressors that precede the onset or

worsening of this symptom suggest that psychological factors

are related to it.

� The patient doesn't consciously feign the symptoms for

material gain (Factitious Disorder) or to occupy the sick role

(Malingering).


Research on Conversion Blindness

• What happens if a researcher asks a person with conversion blindness to “guess” in a recognition task? (e.g., is the bear on the right or left?)

• the person responds at a level significantly above chance.

• malingerers respond at a level below chance.



2) Somatization Disorder

� patient complains of at least 8 symptoms:

– four pain symptoms (e.g., back, joints, abdomen)

– 2 or more gastrointestinal symptoms (e.g.,nausea, bloating,

vomiting)

– 1 or more sexual symptoms (e.g., difficulties with erection or

ejaculation, irregular menses)

– 1 or more of pseudoneurological symptoms (e.g., paralyzed

muscles, trouble swallowing, loss of voice, double vision)

� clinical presentation

– histrionic - la belle indifference



3) Hypochondriasis

� belief that one has a serious disease (e.g., brain cancer)

� minimum 6 month duration

� These ideas are not delusional (as in Delusional Disorder)

and are not restricted to concern about appearance (as in

Body Dysmorphic Disorder).

� They cause distress that is clinically important or impair

work, social or personal functioning.

� “doctor shopping”



4) Pain Disorder

� preoccupation with pain symptoms

� complaints seem obsessive - last at least 6 months

� no known biological origin

� The person's presenting problem is clinically important pain

in one or more body areas.

� The pain causes distress that is clinically important or impairs

work, social or personal functioning.

� Psychological factors seem important in the onset,

maintenance, severity or worsening of the pain.



5) Body Dysmorphic Disorder� preoccupation with an imagined physical

defect

� common complaints:

– nose, mouth, ears

� common result:

– unnecessary plastic surgeries


Diagnosing Somatoform Disorders

� First rule out intentional deception

– Malingering� Feigning condition for external gain

– Factitious Disorder � Intentionally feigning condition


False Symptoms Can Be Intentional: Factitious Disorders

� also called Munchausen’s Syndrome

� motivation is conscious and to assume the sick role

� no other incentives (money, attention, etc.) present

� Munchausen’s by proxy: intentionally induce sickness in one’s child to assume the sick role!


Etiology

� Biological factors

– possibility of misdiagnosis

� Psychological factors

– imagined or real trauma

– primary gain (symptoms may function to protect conscious

mind)

– secondary gain (symptoms may help patient to avoid

responsibility)

� Social factors

– culturally-specific anxiety


Treatment of Somatoform Disorders

� Traditionally, little empirical testing

� Cognitive-behavioural approach

– Pain Disorder: reward successful coping

� Medical approach

– antidepressants

�need for physician empathy


Case Study: Lt.-Gen. Roméo Dallaire

� PTSD due to trauma during Rwandan conflict

(1993-1994)

� Largely helpless during the genocide

� Fired upon, received death threats,

witnessed massacre of staff

� Now prominent advocate for treatment of

PTSD in Canadian military

chapter 7 acute and posttraumatic stress disorders ... · the individual has three (or more) of the...

Documents