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Chapter 6 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Disorders of Trauma and Stress Stress, Coping, and the Anxiety Response • The state of stress has two components: – _____________ – event that creates demands – _____________ – person's reactions to the demands – People who sense that they have the ability and resources to cope are more likely to take stressors in stride and respond well Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Influenced by how we judge both the event and our capacity to react to the event effectively Stress, Coping, and the Anxiety Response • Stress reactions, and the fear they produce, are often at play in psychological disorders Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • When we view a stressor as threatening, the natural reaction is arousal and fear Stress, Coping, and the Anxiety Response • Stress and psychological disorders • Stress and physical (psychophysiological) disorders – These disorders are listed in the DSM-5 under “psychological factors affecting medical condition” Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Acute stress disorder – Posttraumatic stress disorder (PTSD) – The DSM-5 lists these as “trauma and stressorrelated disorders” Stress and Arousal: The Fight-or-Flight Response • The features of arousal and fear are set in motion by the hypothalamus – Two important systems are activated: – An extensive network of nerve fibers that connect the central nervous system (the brain and spinal cord) to all other organs of the body • Endocrine system – A network of glands throughout the body that release hormones Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Autonomic nervous system (ANS) Stress and Arousal: The Fight-or-Flight Response – Sympathetic nervous system pathway – Hypothalamic-pituitary-adrenal pathway • Hypothalamus signals the pituitary gland, which stimulates the adrenal cortex to release corticosteroids – stress hormones – into the bloodstream Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • There are two pathways, or routes, by which the ANS and the endocrine system produce arousal and fear reactions: The Psychological Stress Disorders • Acute stress disorder – Symptoms begin within four weeks of event and last for less than one month – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Posttraumatic stress disorder (PTSD) The Psychological Stress Disorders – – – – Reexperiencing the traumatic event Avoidance Reduced responsiveness Increased arousal, anxiety, and guilt Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Aside from the differences in onset and duration, the symptoms of acute stress disorders and PTSD are almost identical: • 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 • Around two-thirds seek treatment at some point • Ratio of women to men is 2:1 • In addition, people with low incomes are twice as likely as people with higher incomes to experience one of the stress disorders • Some events – including combat, disasters, abuse, and victimization – are more likely to cause disorders than others Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved What Triggers Acute and Posttraumatic Stress Disorders? What Triggers Acute and Posttraumatic Stress Disorders? • Combat and stress disorders • As many as 29% of Vietnam combat veterans suffered acute or posttraumatic stress disorders – An additional 22% had some stress symptoms – 10% still experiencing problems • A similar pattern is currently unfolding among veterans of wars in Afghanistan and Iraq Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Called “shell shock” or “combat fatigue” – Post-Vietnam War clinicians discovered that soldiers also experienced psychological distress after combat What Triggers Acute and Posttraumatic Stress Disorders? • Disasters and stress disorders • Types of disasters include earthquakes, floods, tornadoes, fires, airplane crashes, and serious car accidents • Because they occur more often, civilian traumas have been implicated in stress disorders at least 10 times as often as combat traumas Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Acute or posttraumatic stress disorders may also follow natural and accidental disasters What Triggers Acute and Posttraumatic Stress Disorders? • Victimization and stress disorders – People who have been abused or victimized often experience lingering stress symptoms • Terrorism and torture – The experience of terrorism or the threat of terrorism often leads to posttraumatic stress symptoms, as does the experience of torture Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Research suggests that more than one-third of all victims of physical or sexual assault develop PTSD • PTSD can sometimes be a factor in the commission of crimes • How much should juries and judges take a defendant’s PTSD into consideration when arriving at a verdict? Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Combat Trauma Takes the Stand Why Do People Develop Acute and Posttraumatic Stress Disorders? • Clearly, extraordinary trauma can cause a stress disorder Copyright © 2015 by Worth Publishers. All rights reserved – However, the event alone may not be the entire explanation Abnormal Psychology | Ronald J. Comer | Ninth Edition Why Do People Develop Acute and Posttraumatic Stress Disorders? • Biological and genetic factors Copyright © 2015 by Worth Publishers. All rights reserved – Traumatic events trigger physical changes in the brain and body that may lead to severe stress reactions and, in some cases, to stress disorders Abnormal Psychology | Ronald J. Comer | Ninth Edition Why Do People Develop Acute and Posttraumatic Stress Disorders? • Personality factors – Some studies suggest that people with certain personalities, attitudes, and coping styles are particularly likely to develop stress disorders – Preexisting high anxiety – Negative worldview – A set of positive attitudes (called resiliency or hardiness) is protective against developing stress disorders Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Risk factors include: 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Researchers have found that certain childhood experiences increase risk for later stress disorders – Risk factors include: Why Do People Develop Acute and Posttraumatic Stress Disorders? • Social support Copyright © 2015 by Worth Publishers. All rights reserved – People whose social support systems are weak are more likely to develop a stress disorder after a traumatic event Abnormal Psychology | Ronald J. Comer | Ninth Edition Why Do People Develop Acute and Posttraumatic Stress Disorders? • Multicultural factors • It seems that Hispanic Americans might be more vulnerable to PTSD than other cultural groups – Possible explanations include cultural beliefs systems about trauma and the cultural emphasis on social relationships and social support Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – There is a growing suspicion among clinical researchers that the rates of PTSD may differ among ethnic groups in the US Why Do People Develop Acute and Posttraumatic Stress Disorders? • Severity of the trauma • Especially risky: Mutilation and severe injury; witnessing the injury or death of others Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Generally, the more severe the trauma and the more direct one's exposure to it, the greater the likelihood of developing a stress disorder How Do Clinicians Treat Acute and Posttraumatic Stress Disorders? – General goals: • End lingering stress reactions • Gain perspective on painful experiences • Return to constructive living Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • 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 How Do Clinicians Treat Acute and Posttraumatic Stress Disorders? • Treatment for combat veterans – Drug therapy • Antianxiety and antidepressant medications are most common • 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; rap groups Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Behavioral exposure techniques • Exposure-based therapy may be the single most helpful intervention for people with PTSD • In virtual reality therapy, PTSD clients use wraparound goggles and joysticks to navigate their way through a computer-generated military convoy, battle, or bomb attack in a landscape that looks like Iraq or Afghanistan. • Can you design a virtual reality exposure treatment program for people with social anxiety disorder? Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Virtual Reality Therapy: Better than the Real Thing? How Do Clinicians Treat Acute and Posttraumatic Stress Disorders? • Psychological debriefing – A form of crisis intervention that has victims of trauma talk extensively about their feelings and reactions within days of the critical incident – – – – Normalize responses to the disaster Encourage expressions of anxiety, anger, and frustration Teach self-help skills Provide referrals Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Four-stage approach: Dissociative Disorders – Our recall of past experiences helps us to react to present events and guides us in making decisions about the future – People sometimes experience a major disruption of their memory: • They may not remember new information • They may not remember old information Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • The key to our identity – the sense of who we are and where we fit in our environment – is memory Dissociative Disorders – In such disorders, one part of the person's memory typically seems to be dissociated, or separated, from the rest Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • When such changes in memory lack a clear physical cause, they are called “dissociative” disorders Dissociative Disorders – Dissociative amnesia – Dissociative fugue – Dissociative identity disorder (multiple personality disorder) – Depersonalization-derealization disorder Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Types of dissociative disorders include: Dissociative Amnesia – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • People with dissociative amnesia are unable to recall important information, usually of an upsetting nature, about their lives Dissociative Amnesia – Localized – most common type; loss of all memory of events occurring within a limited period – Selective – loss of memory for some, but not all, events occurring within a period – Generalized – loss of memory beginning with an event, but extending back in time; may lose sense of identity; may fail to recognize family and friends – Continuous – forgetting continues into the future; quite rare in cases of dissociative amnesia Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Dissociative amnesia may be: Dissociative Fugue – For some, the fugue is brief – a matter of hours or days – and ends suddenly – For others, the fugue is more severe: people may travel far from home, take a new name and establish new relationships, and even a new line of work; some display new personality characteristics • Fugues tend to end abruptly Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • People with dissociative fugue not only forget their personal identities and details of their past, but also flee to an entirely different location Dissociative Identity Disorder (Multiple Personality Disorder) Copyright © 2015 by Worth Publishers. All rights reserved • A person with dissociative identity disorder (DID; formerly multiple personality disorder) develops two or more distinct personalities (subpersonalities) each with a unique set of memories, behaviors, thoughts, and emotions Abnormal Psychology | Ronald J. Comer | Ninth Edition Dissociative Identity Disorder (Multiple Personality Disorder) • At any given time, one of the subpersonalities dominates the person's functioning • Most cases are first diagnosed in late adolescence or early adulthood – Symptoms generally begin in childhood after episodes of abuse • Typical onset is before age 5 • Women receive the diagnosis three times as often as men Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Usually one of these subpersonalities – called the primary, or host, personality – appears more often than the others – The transition from one subpersonality to the next (“switching”) is usually sudden and may be dramatic How Do Subpersonalities Interact? – Mutually amnesic relationships – subpersonalities have no awareness of one another – Mutually cognizant patterns – each subpersonality is well aware of the rest – One-way amnesic relationships – most common pattern; some personalities are aware of others, but the awareness is not mutual • Those who are aware (“co-conscious subpersonalities”) are “quiet observers” Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Generally there are three kinds of relationships: How Do Subpersonalities Interact? • Investigators used to believe that most cases of the disorder involved two or three subpersonalities • There have been cases of more than 100 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Studies now suggest that the average number is much higher – 15 for women, 8 for men How Do Subpersonalities Differ? • Subpersonalities often display dramatically different characteristics, including: – Identifying features • Subpersonalities may differ in features as basic as age, sex, race, and family history • Although encyclopedic information is not usually affected by dissociative amnesia or fugue, in DID it is often disturbed • It is not uncommon for different subpersonalities to have different abilities, including being able to drive, speak a foreign language, or play an instrument – Physiological responses • Researchers have discovered that subpersonalities may have physiological differences, such as differences in autonomic nervous system activity, blood pressure levels, and allergies Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Abilities and preferences Dissociative Identity Disorder (Multiple Personality Disorder) – Traditionally, DID was believed to be rare – 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • How common is DID? How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder? – Older explanations have not received much investigation – Newer viewpoints, which combine cognitive, behavioral, and biological principles, have captured the interest of clinical scientists Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • A variety of theories have been proposed to explain dissociative disorders How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder? • The psychodynamic view • People fight off anxiety by unconsciously preventing painful memories, thoughts, or impulses from reaching awareness – In this view, dissociative amnesia and fugue are single episodes of massive repression – DID is thought to result from a lifetime of excessive repression, motivated by very traumatic childhood events Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Psychodynamic theorists believe that dissociative disorders are caused by repression, the most basic ego defense mechanism How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder? • The psychodynamic view • Some individuals with DID do not seem to have these experiences of abuse • Further, why might only a small fraction of abused children develop this disorder? Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Most of the support for this model is drawn from case histories, which report brutal childhood experiences, yet: How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder? • The behavioral view • Momentary forgetting of trauma leads to a drop in anxiety, which increases the likelihood of future forgetting • Like psychodynamic theorists, behaviorists see dissociation as escape behavior – Also like psychodynamic theorists, behaviorists rely largely on case histories to support their view of dissociative disorders • Moreover, these explanations fail to explain all aspects of these disorders Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Behaviorists believe that dissociation grows from normal memory processes and is a response learned through operant conditioning: How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder? • State-dependent learning • 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 Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – 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 How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder? – People who are prone to develop dissociative disorders may have state-to-memory links that are unusually rigid and narrow; each thought, memory, and skill is tied exclusively to a particular state of arousal, so that they recall a given event only when they experience an arousal state almost identical to the state in which the memory was first acquired Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • State-dependent learning How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder? • Self-hypnosis • Called “hypnotic amnesia,” this phenomenon has been demonstrated in research studies with word lists • The parallels between hypnotic amnesia and dissociative disorders are striking and have led researchers to conclude that dissociative disorders may be a form of self-hypnosis Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Although hypnosis can help people remember events that occurred and were forgotten years ago, it can also help people forget facts, events, and their personal identity How Are Dissociative Amnesia and Dissociative Identity Disorder Treated? • People with dissociative amnesia and fugue often recover on their own • In contrast, people with DID usually require treatment to regain their lost memories and develop an integrated personality – Treatment for dissociative amnesia and fugue tends to be more successful than treatment for DID Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – Only sometimes do their memory problems linger and require treatment How Do Therapists Help People With Dissociative Amnesia And Fugue? – Psychodynamic therapists guide patients to search their unconscious and bring forgotten experiences into consciousness – In hypnotic therapy, patients are hypnotized and guided to recall forgotten events – Sometimes intravenous injections of barbiturates are used to help patients regain lost memories • Often called “truth serums,” the key to the drugs' success is their ability to calm people and free their inhibitions Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • The leading treatments for these disorders are psychodynamic therapy, hypnotic therapy, and drug therapy How Do Therapists Help Individuals With DID? • Unlike victims of dissociative amnesia or fugue, people with DID do not typically recover without treatment Copyright © 2015 by Worth Publishers. All rights reserved – Treatment for this pattern, like the disorder itself, is complex and difficult Abnormal Psychology | Ronald J. Comer | Ninth Edition How Do Therapists Help Individuals With DID? – Once a diagnosis of DID has been made, therapists try to bond with the primary personality and with each of the subpersonalities – As bonds are forged, therapists try to educate the patients and help them recognize the nature of the disorder • Some use hypnosis or video as a means of presenting other subpersonalities – Many therapists recommend group or family therapy Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved • Recognizing the disorder How Do Therapists Help Individuals With DID? • Recovering memories • These techniques tend to work slowly in cases of DID Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – To help patients recover missing memories, therapists use many of the approaches applied in other dissociative disorders, including psychodynamic therapy, hypnotherapy, and drug treatment How Do Therapists Help Individuals With DID? • Integrating the subpersonalities • Many patients distrust this final treatment goal and their subpersonalities see integration as a form of death – Once the subpersonalities are integrated, further therapy is typically needed to maintain the complete personality and to teach social and coping skills to prevent later dissociations Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – The final goal of therapy is to merge the different subpersonalities into a single, integrated identity – Integration is a continuous process; fusion is the final merging • DSM-5 categorizes depersonalizationderealization disorder as a dissociative disorder, even though it is not characterized by the memory difficulties found in the other dissociative disorders • Its central symptom is persistent and recurrent episodes of depersonalization (the sense that one’s own mental functioning or body are unreal or detached) and/or derealization (the sense that one’s surroundings are unreal or detached) Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved Depersonalization-Derealization Disorder Depersonalization-Derealization Disorder • People with this disorder feel as though they have become separated from their body and are observing themselves from outside • Depersonalization experiences by themselves do not indicate a depersonalization disorder – Transient depersonalization reactions are fairly common – The symptoms of a depersonalization disorder are persistent or recurrent, cause considerable distress, and interfere with social relationships and job performance Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – This sense of unreality can extend to other sensory experiences and behavior Depersonalization-Derealization Disorder • The disorder occurs most frequently in adolescents and young adults, hardly ever in people older than 40 • Few theories have been offered to explain the disorder and little research has been conducted on the problem Abnormal Psychology | Ronald J. Comer | Ninth Edition Copyright © 2015 by Worth Publishers. All rights reserved – The disorder comes on suddenly and tends to be long-lasting