Download acute and postraumatic stress disorders, dissociative disorders, and

CHAPTER SEVEN
ACUTE AND
POSTRAUMATIC STRESS
DISORDERS, DISSOCIATIVE
DISORDERS, AND
SOMATOFORM DISORDERS
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.
ACUTE AND POSTRAUMATIC
STRESS DISORDERS
Reexperiencing
Avoidance
 Repeated, distressing
 Attempts of avoid
images or thoughts
 Intrusive flashbacks
 Horrifying dreams
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 anxiety
Dissociative symptoms
 Predicts a worse
 Dazed and act “spaced
prognosis
 Hypervigilance
 Restlessness,
agitation, and
irritability
 Exaggerated startle
response
out”
 Depersonalization
 Derealization
 Dissociative amnesia
ACUTE AND POSTRAUMATIC
STRESS DISORDERS
 Comorbidity
 High
for depression, other anxiety disorders,
and substance abuse
 Anger – usually very prominent; Risk for
suicide
 Frequency
 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
Classical
theory
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
ACUTE AND POSTRAUMATIC
STRESS DISORDERS
CBT for PTSD
EMDR (Eye Movement
Desensitization and
Reprocessing)
 The most effective
 Francine Sharpiro
treatment for PTSD is
reexposure to trauma.
 Prolonged exposure
 Imagery rehearsal
therapy
 Cognitive restructuring
 Includes rapid back-
and-forth eye
movements
 Prolonged exposure
appears to be the
“active ingredient”
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.
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.
Classifying Dissociative Disorders
Classifying Dissociative Disorders
Classifying Dissociative Disorders
 Dissociative Fugue
Classifying Dissociative Disorders
 Dissociative 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 Perspectives
 Freud’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
SOMATOFORM DISORDERS
Body dysmorphic disorder
Malingering and factitious
disorder
 Preoccupation with
 Pretending to have a
some imagined defect
in appearance
 Repeated visits to the
plastic surgeon
 Exceeds normal worry
about imperfections
physical illness in order
to achieve some
external gain ($$$)
 Factitious disorder is
motivated by a desire
to assume a sick role
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 later
 Psychological 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 mental
health professional.