PTSD Dissociation

Chapter 7Acute and Posttraumatic Stress Disorders, Dissociative Disorders, and Somatoform Disorders: 

Chapter 7 Acute and Posttraumatic Stress Disorders, Dissociative Disorders, and Somatoform Disorders Copyright © 2006 Pearson Education Canada Inc.

Overview: 

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: 

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: 

DSM IV-TR: Defining Trauma event: actual/threatened death or serious injury to self or others response: intense fear, helplessness, andamp; horror emphasizes subjective response

Types of Trauma: 

Types of Trauma - Sexual Abuse - Physical Abuse - War related - Terminal illness - Gang Violence - Natural Disaster

Characterological Impacts: 

Characterological Impacts Damaged sense of control Anxiety Dysregulation Repression Shame/Guilt Erosion of Trust

Acute and Posttraumatic Stress Disorders: 

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): 

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

Acute stress disorder (ASD): 

Acute stress disorder (ASD) 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)

Acute stress disorder (ASD): 

Acute stress disorder (ASD) 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): 

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%

Posttraumatic stress disorder (PTSD): 

Posttraumatic stress disorder (PTSD) 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

Posttraumatic stress disorder (PTSD): 

Posttraumatic stress disorder (PTSD) 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)

Posttraumatic stress disorder (PTSD): 

Posttraumatic stress disorder (PTSD) 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: 

ASD andamp; PTSD: Typical Symptoms Re-experiencing trauma Avoidance of associated stimuli Persistent arousal/anxiety Survivors guilt ASD not PTSD: dissociative symptoms

1. Re-experiencing Trauma: 

1. Re-experiencing Trauma Persistent, horrific images (e.g., nightmares) Flashbacks – spontaneous memories of trauma

2. Avoidance: 

2. Avoidance thoughts or feelings about the event associated people, places, or activities numbing of responsiveness

3. Arousal/Anxiety: 

3. Arousal/Anxiety hypervigilance sleep/concentration difficulties irritability heightened startle response

Historical Perspective : 

Historical Perspective 'combat neurosis' 'shell shock' interest in PTSD amplifies following Vietnam War

Etiology : 

Etiology Social factors level of exposure post-trauma social support Psychological factors two-factor theory Classical and Operant conditioning

Prevention/Treatment: 

Prevention/Treatment prevention through early intervention critical incident stress debriefing (CISD) anti-depressants (but not anxiolytics) CBT exposure therapy EMDR

Dissociative Disorders: 

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): 

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: 

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: 

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: 

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: 

DID Controversies problem of self-report reliability of recovered memories infantile amnesia scientific evidence for false memories

Skepticism regarding DID: 

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 : 

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: 

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: 

Treatment of Dissociative Disorders Psychological approach recovery of traumatic memories hypnosis main objective: integration of personalities Medical approach distress reduction

Somatoform Disorders: 

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 : 

Typical Symptoms: 3 Variations single impairment of somatic system (e.g., paralysis, blindness) multiple physical symptoms (e.g., pain andamp; gastrointestinal symptoms) Preoccupation with a single disease (e.g., cancer)

5 types of somatoform disorders: 

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: 

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.

5 types of somatoform disorders: 

5 types of somatoform disorders 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

5 types of somatoform disorders: 

5 types of somatoform disorders 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'

5 types of somatoform disorders: 

5 types of somatoform disorders 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 types of somatoform disorders: 

5 types of somatoform disorders 5) Body Dysmorphic Disorder preoccupation with an imagined physical defect common complaints: nose, mouth, ears common result: unnecessary plastic surgeries

Diagnosing Somatoform Disorders: 

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: 

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: 

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: 

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: 

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