Chapter 7: Acute & PTSD, Dissociative, & Somatoform Disorders

1. Chapter 7: Acute & PTSD, Dissociative, & Somatoform Disorders Fall, 2012 Dr. Mary L. Flett, Instructor

2. Overview • These disorders, while differing in many ways, share one common similarity: dissociation • Limited research on this area • Conflicting theories and schools of belief • Lack of empirical research; lots of anecdotal • At the core – is the mind all powerful?

3. Acute & Post-traumatic Stress Disorders (PTSD) • Traumatic stress is defined as an event that involves actual or threatened death or serious injury to self or others, and creates intense feelings of fear, helplessness, or horror • Rape • Military combat • Bombings • Airplane crashes • Earthquakes • Fires • Automobile wrecks

4. Acute & Post-traumatic Stress Disorders (PTSD) • Acute stress disorder occurs within 4 weeks after the exposure and is characterized by: • dissociative symptoms • re-experiencing the event • avoidance of reminders • marked anxiety or arousal • PTSD the symptoms are longer lasting or delayed

5. Acute & Post-traumatic Stress Disorders (PTSD) • Dissociative symptoms in PTSD include • feeling dazed or spaced out • a marked sense of unreality (derealization) • the inability to recall important aspects of the trauma (dissociative amnesia) • numbing or detachment

6. Acute & Post-traumatic Stress Disorders (PTSD) • Trauma is defined as • the experience of an event involving actual or threatened death or serious injury to self or others • a response of intense fear, helplessness, or horror in reaction to the event • Different trauma may have unique psychological consequences • 9/11 experiences suggest those not directly exposed to trauma suffered at least an acute stress response • disaster & emergency workers are less likely to experience stress response, but do need to attend to their own issues

7. Acute & Post-traumatic Stress Disorders (PTSD) • Co-morbidity high for depression, other anxiety disorders, and alcohol abuse • Increased suicide risk • Differential diagnosis between adjustment disorder and ASD looks at “normal” reactions to painful stressors such as losing a job

8. Acute & Post-traumatic Stress Disorders (PTSD) • Frequency of Trauma, PTSD, & ASD • Traumatic stressors are common, not rare as previously believed • Women are especially likely to develop PTSD if raped; men if in combat • Children and women more vulnerable to PTSD • Members of marginalized communities more likely to experience PTSD • Most common experience is sudden, unexpected death of a loved one

9. Acute & Post-traumatic Stress Disorders (PTSD) • Frequency of Trauma, PTSD, & ASD • Risk is higher for those who engage in risky behavior, have a history of conduct disorders, or are extroverts • Individuals who are “neurotic” (anxious and easily upset) more likely to develop PTSD • If previous trauma experienced, vulnerability to a second episode is higher • Family history of mental illness is also a predictor

10. Acute & Post-traumatic Stress Disorders (PTSD) • Course & Outcome • Best predictors of future PTSD • numbing • depersonalization • sense of reliving the experience • Sx generally diminish over time with greatest improvement seen within first year • Sx may remain, however, for as long as 40-50 years

11. Acute & Post-traumatic Stress Disorders (PTSD) • Causes • Social factors include degree of exposure • Lack of support or denial of symptoms • Environmental influence is higher than genetic • Genes appear to contribute most strongly to arousal/anxiety symptoms and least strongly to re-experiencing

12. Acute & Post-traumatic Stress Disorders (PTSD) • Biological Effects of Exposure • Consequences include • alterations in functioning and structure of the amygdala • Sympathetic nervous system appears to be aroused and the fear response sensitized in PTSD • No direct evidence of brain damage due to PTSD • Damage may be pre-existing • Brain trauma is not same as emotional response

13. Acute & Post-traumatic Stress Disorders (PTSD) • Psychological Factors • Two-Factor Theory states that classical conditioning creates fears when paired; operant conditioning maintains avoidance by reducing fear • Avoidance prevents the extinction of anxiety through exposure • Dissociation may be an unconscious defense that helps cope with the trauma

14. Acute & Post-traumatic Stress Disorders (PTSD) • Psychological Factors • Emotional processing • victim must engage emotionally with the traumatic memory • victim must find a way to articulate and organize their chaotic experience • victim must come to believe that, despite their experience, the world is not a terrible place • Assuming all three steps are completed, victim may experience post-traumatic growth

15. Acute & Post-traumatic Stress Disorders (PTSD) • Prevention & Treatment • Offering immediate psychological help to victims is a common goal • Critical incident stress debriefing (CISD) • designed to intervene as closely to the event as possible • if done correctly, may mitigate symptoms, but no evidence to support assertion that CISD prevents PTSD • if done poorly, may actually exacerbate symptoms • Returning to normal routine quickly appears to be beneficial, whether this is combat or work

16. Acute & Post-traumatic Stress Disorders (PTSD) • Treatment of ASD not well researched; PTSD has received more study • Most effective treatment for PTSD is re-exposure to trauma • confronting feared situations • imagery rehearsal therapy • prolonged exposure • emotional processing & making meaning

17. Acute & Post-traumatic Stress Disorders (PTSD) • Eye movement desensitization & reprocessing (EMDR) is another technique • Has research validity • Is as effective as prolonged exposure • May be ineffective in hands of poorly trained therapist

18. Dissociative Disorders • Dissociative disorders are characterized by persistent, maladaptive disruptions in the integration of memory, consciousness, or identity • May be all “hooey” • May be legitimate, and under reported • May be rare

19. Dissociative Disorders • Hysteria & the Unconscious • From the Greek for uterus (hystera); reflects ancient view that a woman’s desire to have a baby, when frustrated, cause these symptoms • Freud (Charcot & Janet) all believed that hysteria could be treated by hypnosis • Freud considered dissociation from reality to be a normal process; an expression of unconscious conflict • Janet believed it was a pathological process • Freud had better media exposure and his theory dominated

20. Dissociative Disorders • Current research on “the unconscious” • Explanations include • rational and experiential systems (Epstein) • implicit and explicit memory (Schacter) • Hypnosis & altered states of consciousness • Suggestibility? • Dissociative experience?

21. Dissociative Disorders • Symptoms of Dissociative Disorders • Depersonalization • Psychogenic amnesia • inability to recall events, persons, or emotions associated with a trauma • Dissociative Fugue • sudden, unplanned travel, the inability to remember details about the past, and confusion about identity or the assumption of a new identity • Recovered memory

22. Dissociative Disorders • Diagnosis of Dissociative Disorders • Four subtypes found in DSM • Dissociative fugue (travel away from home; inability to recall) • Dissociative amnesia (sudden inability to recall extensive & important personal information) • Depersonalization disorder (feelings of being detached from self) • Dissociative Identity Disorder (DID) (existence of two or more “personalities” within one individual

23. Dissociative Disorders • Frequency of Dissociative Disorders • Dominant thinking is that these are very, very rare • Minority thinking makes a strong case that individuals are mis-diagnosed (schizophrenics, BPD, et al) and not being treated • Other explanations include role enactment

24. Dissociative Disorders • Causes • Psychological Factors • precipitated by a traumatic experience • state-dependent learning • Biological Factors • Little evidence has been gathered • Social Factors • iatrogenesis – the manufacture of a disorder by its treatment

25. Dissociative Disorders • Treatment • Focus is on uncovering and recounting traumatic events • assumes that if trauma can be expressed, need for dissociative coping will disappear • Integrating all personalities into a single whole • No systematic research on any one approach has been collected

26. Somatoform Disorders • Symptoms • Complaints about physical symptoms that are “real”, but no medical evidence of the cause can be identified • May involve substantial impairment of sensory or muscular system (blindness or paralysis) • Chronic pain, upset stomach, dizziness • Preoccupation with a particular part of the body or fears of a particular illness

27. Somatoform Disorders • Unnecessary medical treatment • Primary care is point of access • Difficult to evaluate objectively • Result in unnecessary surgery and laboratory testing • May account for ½ of all ambulatory care costs

28. Somatoform Disorders • Diagnosis • Five subcategories • Conversion Disorder (hysterical blindness; paralysis) • Somatization Disorder (history of multiple somatic complaints in the absence of organic impairments) • histrionic • la belle indifference • Hypochondriasis (fear of suffering from physical illness) • Pain Disorder (preoccupation with pain) • Body Dysmorphic Disorder (preoccupation with a particular body part)

29. Somatoform Disorders • Diagnosis • Malingering & Factitious Disorders • Not a psychological problem; intentional, conscious roles • Motivated by desire to assume the sick role (factitious disorder, aka Munchausen Syndrome) • Pretending to be ill to achieve some external gain (Malingering)

30. Somatoform Disorders • Frequency • Lower prevalence today due to improved diagnostic practices • No longer hysteria; now possibly chronic fatigue syndrome, Gulf War syndrome • New category (multisomatoform disorder) is proposed for DSM-V

31. Somatoform Disorders • Gender, SES, and Culture • More common among women, particularly somatization disorder • More common among lower socio-economic groups, and psychological unsophisticated individuals • Cultural implications arise where culture does not allow free expression of emotions, but does accept body pains

32. Somatoform Disorders • Co-morbidity • Occur particularly with depression and anxiety • Frequently linked to antisocial personality disorder • Usually found in different members of the family, not one individual

33. Somatoform Disorders • Causes • Biological Factors • real potential for misdiagnosis • diagnosis by exclusion • Conversion disorder may resolve into a known physical disorder (epilepsy, neurological disease) • Psychological Factors • May be triggered by trauma, but not necessarily • Extra attention; avoidance of undesirable activity • Adopting the “sick role”

34. Somatoform Disorders • Causes • Social Factors • Emotional expression of distress may be unacceptable

35. Somatoform Disorders • Treatment • Operant approaches to chronic pain alter reward system for “pain behavior” • CBT uses cognitive restructuring to address emotional and thought components of pain • Anti-depressants are helpful • Lack of research due to fact that primary care physicians do most of treatment without partnering with psychologists • Patients shop for sympathetic doctors to treat them adding costs to care