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ACUTE AND POSTRAUMATIC STRESS DISORDERS,
DISSOCIATIVE DISORDERS, AND SOMATOFORM
DISORDERS
CHAPTER SEVEN
OVERVIEW
Dissociation – the disruption of the normally integrated mental processes involved in memory, consciousness, identity, or perception.
ACUTE AND POSTRAUMATIC STRESS DISORDERS
Traumatic stress An event that involves actual or
threatened death or serious injury to self or others and creates intense feelings of fear, helplessness, or horror.
ACUTE AND POSTRAUMATIC STRESS DISORDERS
Acute Stress Disorder (ASD) Occurs within four weeks after exposure to a
traumatic stress and characterized by dissociative symptoms as well as: Reexperiencing, avoidance of reminders, and
marked anxiety or arousal.
Posttraumatic Stress Disorder (PTSD) Defined by symptoms of reexperiencing,
avoidance, and arousal, but PTSD is either longer lasting (30+ days) or have a delayed onset.
ACUTE AND POSTRAUMATIC STRESS DISORDERS
The defining symptoms of both acute and posttraumatic stress disorder include: (1) reexperiencing (2) avoidance (3) persistent arousal or anxiety
Dissociative symptoms are common in the immediate aftermath of a trauma, but must be present for the diagnosis of ASD, but not PTSD.
ReexperiencingReexperiencing AvoidanceAvoidance
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
ACUTE AND POSTRAUMATIC STRESS DISORDERS
Arousal or anxietyArousal or anxiety Dissociative symptomsDissociative symptoms
Predicts a worse prognosis
HypervigilanceRestlessness,
agitation, and irritability
Exaggerated startle response
Dazed and act “spaced out”
DepersonalizationDerealizationDissociative
amnesia
ACUTE AND POSTRAUMATIC STRESS DISORDERS
ACUTE AND POSTRAUMATIC STRESS DISORDERS
Comorbidity High for depression, other anxiety
disorders, and substance abuse Anger – usually very prominent; Risk for
suicideFrequency
Prevalence of PTSD: 8% of people living in the United States (10% women, 5% of men)
Rape and assault pose especially high risk for PTSD.
Minorities are more likely experience PTSD. See Figure 7-1
ACUTE AND POSTRAUMATIC STRESS DISORDERS
Biological Effects of Exposure to Trauma People with PTSD show alterations in the
functioning, and perhaps structure, or the amygdala and hippocampus.
The sympathetic nervous system is aroused and the fear response is sensitized in PTSD.
Does trauma change the brain? Differences between people with and without PTSD are correlations.
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.
The risk for PTSD depends on cognitive factors: preparedness, purpose and blame.
Antidepressants such as SSRI’s are helpful Typical anxiety meds not effective
CBT for PTSDCBT for PTSDEMDR (Eye Movement Desensitization and
Reprocessing)
EMDR (Eye Movement Desensitization and
Reprocessing)
The most effective treatment for PTSD is reexposure to trauma.
Prolonged exposureImagery rehearsal
therapyCognitive
restructuring
Francine SharpiroIncludes rapid back-
and-forth eye movements
Prolonged exposure appears to be the “active ingredient”
ACUTE AND POSTRAUMATIC STRESS DISORDERS
DISSOCIATIVE DISORDERS
The symptoms of dissociative disorders are characterized by persistent, maladaptive disruption in the integration of memory, consciousness, or identity.
Controversial and disbelieved by many.
AmnesiaRetrograde 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.
Classifying Dissociative Disorders
Classifying Dissociative Disorders
Classifying Dissociative DisordersDissociative Fugue
Classifying Dissociative DisordersDissociative Identity Disorder
a.k.a. multiple personality disorder
Dissociative Identity Disorder
“Host” personality – retains person’s name and identity and functions in the outside world.
“Persecutory” personalities may be aggressive and hostile.
“Protector” personalities may try to protect the host personality
“Lost time” – loss of memory for events during which another personality was present.
Why should you doubt claims that dissociative identity disorder is
common?1. Most cases diagnosed by a handful of
ardent advocates.2. Frequency (DID in particular) increased
rapidly after release of the very popular book and movie Sybil.
3. The number of personalities claimed to exist has grown rapidly, from a handful to 100 or more.
4. Rarely diagnosed outside of the USA and Canada; (only one case of DID has been reported in Great Britain in the last 25 years.)
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.
DISSOCIATIVE DISORDERS
Causes of Dissociative Disorders Biological Factors
Little to no evidence of biological and genetic factors.
Social Factors Iatrogenesis – the manufacture of a disorder
by its treatments. “cases” were created by the expectations of
therapists?
Psychodynamic PerspectivesFreud’s model
Topographic model
conscious
preconscious
unconscious
SOMATOFORM DISORDERS
Symptoms of Somatoform Disorders Complaints about physical symptoms in the
absence of medical evidence. The problem is very real in the mind,
though not the body. Usual numerous, constantly evolving
complaints such as chronic pain, upset stomach, dizziness.
Worry about a deadly disease despite negative medical evidence.
SOMATOFORM DISORDERS
Diagnosis of Somatoform Disorders Conversion Disorder Symptoms mimic neurological disorders Make no anatomic sense Implies that psychological conflicts are being
converted into physical symptoms Somatization Disorder
History of multiple somatic complaints in the absence of organic impairments.
Eight symptoms, onset prior to age 30
SOMATOFORM DISORDERS
Diagnosis of Somatoform Disorders Hypochondriasis
Fear or belief that one is suffering from a physical illness.
Much more serious than normal or fleeting worries and can lead to substantial impairment in life functioning.
Pain Disorder Preoccupation with pain At risk for developing dependence on
pain medication
Body dysmorphic disorderBody dysmorphic disorder
Malingering and factitious disorderMalingering and factitious disorder
Preoccupation with some imagined defect in appearance
Repeated visits to the plastic surgeon
Exceeds normal worry about imperfections
Pretending to have a physical illness in order to achieve some external gain ($$$)
Factitious disorder is motivated by a desire to assume a sick role
SOMATOFORM DISORDERS
SOMATOFORM DISORDERS
Frequency of Somatoform Disorders Gender, SES and Culture
More common among women (10 times) More common among lower SES Four times more common among
African Americans and higher in Puerto Rico and Latin America
Comorbidity Depression, anxiety, and antisocial
personality disorder
SOMATOFORM DISORDERS
Causes of Somatoform Disorders Biological Factors
Diagnosis by exclusion Perils of this approach – cases where
some medical etiology can emerged laterPsychological Factors
Primary and secondary gain Cognitive tendencies: amplification,
alexithymia (inability to express emotions in words)
FIGURE 7-6
Psychological Factors in Somatoform Disorders
SOMATOFORM DISORDERS
Treatment of Somatoform Disorders Operant approaches to chronic pain
Reward successful coping and adaptation Cognitive behavioral therapy
Cognitive restructuring Antidepressants
Patients are likely to refuse a referral to a mentalhealth professional.
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