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

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 integrityL.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 monthLifetime 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/anxiety4. 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 interventioncritical incident stress debriefing (CISD)anti-depressants (but not anxiolytics)CBTexposure therapyEMDR


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 personalitiesMedical 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

Documents

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