Disorders of Trauma and Stress

1. Disorders of Traumaand Stress Chapter 5

2. Stress, Coping, and the Anxiety Response • The state of stress has two components: • Stressor – event that creates demands • Stress response – person’s reactions to the demands • Influenced by how we judge both the events and our capacity to react to them effectively

3. Stress, Coping, and the Anxiety Response • Extraordinary stress and trauma also play central role in certain psychological disorders: • Acute stress disorder • Posttraumatic stress disorder (PTSD) • …as well as the Dissociative disorders: • Dissociative amnesia • Dissociative identity disorder • Depersonalization-derealization disorder

4. Stress and Arousal: The Fight-or-Flight Response • Features of arousal and fear are set in motion by hypothalamus • Two important systems are activated: • Autonomic nervous system (ANS) • Extensive network of nerve fibers that connect CNS to all other organs • Endocrine system • Network of glands throughout body that release hormones

5. Stress and Arousal: The Fight-or-Flight Response • There are two pathways, or routes, by which the ANS and endocrine system produce arousal and fear reactions: • Sympathetic nervous system pathway • Hypothalamic-pituitary-adrenal pathway

6. The Autonomic Nervous System

7. The Hypothalamic-Pituitary-Adrenal (HPA) Axis

8. Trauma • Usually involves actual or threatened serious injury to self or others • During and immediately after trauma, temporarily experience high levels of arousal and upset

9. Acute and Posttraumatic Stress Disorders • Acute stress disorder (ASD) • Symptoms begin immediately or soon after the traumatic event and last for less than one month • Posttraumatic stress disorder (PTSD) • Symptoms may begin either shortly after the event, or months or years afterward • As many as 80% of all cases of acute stress disorder develop into PTSD

10. Avoidance ACUTE AND POSTRAUMATIC STRESS DISORDERS Re-experiencing Repeated, distressing images or thoughts Intrusive flashbacks Horrifying dreams Attempts of avoid thoughts, feelings related to the event Avoid people, places, or activities that remind them of the event Numbing of responsiveness

11. Dissociative symptoms ACUTE AND POSTRAUMATIC STRESS DISORDERS Arousal or anxiety Predicts a worse prognosis Hypervigilance Restlessness, agitation, and irritability Exaggerated startle response Dazed and act “spaced out” Depersonalization Derealization Dissociative amnesia

12. What Triggers Acute and Posttraumatic Stress Disorders? • Can occur at any age and affect all aspects of life • At least 3.5% of people in the U.S. are affected each year • 7–9% of people in the U.S. are affected sometime during their lifetime • Around two-thirds seek treatment at some point

13. What Triggers Acute and Posttraumatic Stress Disorders? • Ratio of women to men is 2:1 • Low incomes 2x as likely • Victimization, Combat, Disasters, & Abuse

14. Why Do People Develop Acute and Posttraumatic Stress Disorders? • Biological and genetic factors • Traumatic events trigger physical changes in the brain and body that may lead to severe stress reactions and, in some cases, to stress disorders • Some research suggests abnormal especially norepinephrine and cortisol levels • Evidence suggests that once a stress disorder sets in, further biochemical arousal and damage may also occur (especially in the hippocampus and amygdala)

15. Why Do People Develop Acute and Posttraumatic Stress Disorders? • Personality factors • Preexisting high anxiety • Negative worldview • A set of positive attitudes (called resiliency or hardiness) protective

16. Why Do People Develop Acute and Posttraumatic Stress Disorders? • Childhood experiences • An impoverished childhood • Psychological disorders in the family • The experience of assault, abuse, or catastrophe at an early age • Being younger than 10 years old when parents separated or divorced

17. Why Do People Develop Acute and Posttraumatic Stress Disorders? • Social support • People whose social support systems are weak are more likely to develop a stress disorder after a traumatic event • Severity of the trauma • Generally, the more severe the trauma and more direct one’s exposure to it, greater likelihood of developing stress disorder • Especially risky: Mutilation and severe injury; witnessing the injury or death of others

18. ACUTE AND POSTRAUMATIC STRESS DISORDERS • Psychological Factors in ASD and PTSD • Two-factor theory Classical conditioning creates fear when the terror of trauma is paired with the cues associated with it. Operant conditioning maintains avoidance by reducing fear (negative reinforcement). Avoidance prevents the extinction of anxiety through exposure.

19. How Do Clinicians Treat Acute and Posttraumatic Stress Disorders? • About half of all cases of PTSD improve within 6 months; the remainder may persist for years • Treatment procedures vary depending on type of trauma • General goals: • End lingering stress reactions • Gain perspective on painful experiences • Return to constructive living

20. How Do Clinicians Treat Acute and Posttraumatic Stress Disorders? • Treatment • Drug therapy • Anti-anxiety and antidepressant medications are most common • Behavioral exposure techniques • Reduce specific symptoms, increase overall adjustment • Use flooding and relaxation training • Use eye movement desensitization and reprocessing (EMDR) • Insight therapy • Bring out deep-seated feelings, create acceptance, lessen guilt • Often use couple, family, or group therapy formats;

21. Dissociative Disorders • Although their conditions are also triggered by traumatic events, individuals do not typically experience the significant arousal, negative emotions and other symptoms associated with the stress disorders • Instead, their symptoms are characterized by patterns of memory loss and identity change

22. Dissociative Disorders • The key to our identity – the sense of who we are and where we fit in our environment – is memory • In dissociative disorders, one part of the person’s memory typically seems to be dissociated, or separated, from the rest

24. Amnesia • Retrograde Amnesia • Anterograde Amnesia • Is the amnesia biologically-based or psychogenic? • Organic amnesia usually involves personal and general information; also may involve anterograde amnesia. • Psychogenic amnesia usually involves only personal information; also may involve retrograde amnesia.

25. Dissociative Disorders • There are several kinds of dissociative disorders, including: • Dissociative amnesia • Dissociative fugue • Dissociative identity disorder (multiple personality disorder) • Depersonalization-derealization disorder

26. Dissociative Amnesia • People with dissociative amnesia are unable to recall important information, usually of a stressful nature, about their lives • The loss of memory is much more extensive than normal forgetting and is not caused by physical factors • Often an episode of amnesia is directly triggered by a specific upsetting event

27. Dissociative Amnesia • Dissociative amnesia may be: • Localized • Selective • Generalized • Continuous

28. Dissociative Fugue • Persons not only forget their personal identities and details of their past, but also flee to an entirely different location.

29. Dissociative Identity Disorder • A person with dissociative identity disorder develops two or more distinct personalities, called “subpersonalities”, each with a unique set of memories, behaviors, thoughts, and emotions

30. Dissociative Identity Disorder • At any given time, one of sub-personalities dominates person’s functioning • Usually one of these sub-personalities – called the primary, or host, personality – appears more often than others • Transition from one sub-personality to next (“switching”) is usually sudden and may be dramatic

31. Dissociative Identity Disorder • How do sub-personalities interact? • The relationship between or among sub-personalities varies from case to case • Generally there are three kinds of relationships: • Mutually amnesic relationships • Mutually cognizant patterns • One-way amnesic relationships

32. Dissociative Identity Disorder • Sub-personalities often display dramatically different characteristics, including: • Identifying features • Sub-personalities may differ in features as basic as age, sex, race, and family history • Abilities and preferences • It is not uncommon for different subpersonalities to have different abilities, including being able to drive, speak a foreign language, or play an instrument

33. Dissociative Identity Disorder • Subpersonalities often display dramatically different physiological responses • Differences in autonomic nervous system activity, blood pressure levels, and allergies

34. Dissociative Identity Disorder • Traditionally, DID was believed to be rare • Some researchers even argue that many or all cases are iatrogenic; that is, unintentionally produced by practitioners

35. Dissociative Identity Disorder • The number of people diagnosed with the disorder has been increasing • Although the disorder is still uncommon, thousands of cases have been documented in the U.S. and Canada alone • Two factors may account for this increase: • A growing number of clinicians believe that the disorder does exist and are willing to diagnose it • Diagnostic procedures have become more accurate • Despite changes, many clinicians continue to question the legitimacy of this category

36. Why should you doubt claims that dissociative identity disorder is common? 1. Most cases of dissociative disorders are diagnosed by a handful of ardent advocates. 2. The frequency of the diagnosis of dissociative disorders in general and DID in particular increased rapidly after release of the very popular book and movie Sybil. 3. The number of personalities claimed to exist in cases of DID has grown rapidly, from a handful to 100 or more. 4. Dissociative disorders are rarely diagnosed outside of the United States and Canada; for example, only one unequivocal case of DID has been reported in Great Britain in the last 25 years).

37. DISSOCIATIVE DISORDERS • Causes of Dissociative Disorders • Psychological Factors in Dissociative Disorders • Little controversy that dissociative amnesia and fugues can be precipitated by trauma. • Trauma is “suspected” in DID, but much of the data is retrospective. • The vast majority of trauma victims do not develop a dissociative disorder.

38. PSYCHODYNAMIC PERSPECTIVES • Freud’s model Topographic model conscious preconscious unconscious

39. How Do Theorists Explain Dissociative Amnesia and DID? • State-dependent learning • If people learn something when they are in a particular state of mind, they are likely to remember it best when they are in the same condition • This link between state and recall is called state-dependent learning • This model has been demonstrated with substances and mood and may be linked to arousal levels

40. How Are Dissociative Amnesia and DID Treated? • Therapists usually try to help the client by: • Recognizing the disorder • Recovering memories • Integrating the subpersonalities