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Chapter 7 Acute and Posttraumatic Stress Disorders, Dissociative Disorders, and Somatoform Disorders Copyright © 2006 Pearson Education Canada Inc. Quote of the Day Remembrance has a Rear and Front, 'Tis something like a HouseIt has a Garret also For Refuse and the Mouse. -- Emily Dickinson Copyright © 2006 Pearson Education Canada Inc. 2 Overview Focus: normal vs. pathological reactions to trauma Dissociation – disruption of the normally integrated processes of memory consciousness, identity, or perception Anxiety, dissociation, and stress are linked – much disagreement about the link Copyright © 2006 Pearson Education Canada Inc. 3 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 Copyright © 2006 Pearson Education Canada Inc. 4 Acute stress disorder (ASD) within 4 weeks after exposure to trauma characterized by – – – dissociative symptoms re-experiencing of the event marked anxiety/arousal Copyright © 2006 Pearson Education Canada Inc. 5 Posttraumatic stress disorder (PTSD) like ASD, characterized by – – – dissociative symptoms re-experiencing of the event marked anxiety/arousal Unlike ASD, symptoms long-lasting Copyright © 2006 Pearson Education Canada Inc. 6 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 Copyright © 2006 Pearson Education Canada Inc. 7 ASD & PTSD: Typical Symptoms 1. 2. 3. Re-experiencing trauma Avoidance of associated stimuli Persistent arousal/anxiety ASD not PTSD: dissociative symptoms Copyright © 2006 Pearson Education Canada Inc. 8 1. Re-experiencing Trauma Persistent, horrific images (e.g., nightmares) Flashbacks – spontaneous memories of trauma Copyright © 2006 Pearson Education Canada Inc. 9 2. Avoidance thoughts or feelings about the event associated people, places, or activities numbing of responsiveness Copyright © 2006 Pearson Education Canada Inc. 10 3. Arousal/Anxiety hypervigilance sleep/concentration difficulties irritability heightened startle response Copyright © 2006 Pearson Education Canada Inc. 11 ASD: dissociative symptoms Depersonalization – feeling outside of oneself or one’s environment Derealization – marked sense of unreality of oneself or one’s environment Copyright © 2006 Pearson Education Canada Inc. 12 Historical Perspective neurosis” “shell shock” interest in PTSD amplifies following Vietnam War “combat Copyright © 2006 Pearson Education Canada Inc. 13 DSM IV-TR: Defining Trauma event: actual/threatened death or serious injury to self or others response: intense fear, helplessness, & horror emphasizes subjective response Copyright © 2006 Pearson Education Canada Inc. 14 Etiology Social factors – – Biological factors – – level of exposure post-trauma social support genetic amygdala Psychological factors – – two-factor theory Edna Foa: emotional processing Copyright © 2006 Pearson Education Canada Inc. 15 Prevention/Treatment critical incident stress debriefing (CISD) anti-depressants (but not anxiolytics) CBT Copyright © 2006 Pearson Education Canada Inc. 16 Dissociative Disorders persistent problems in the integration of memory, consciousness, or identity perhaps best interpreted from a psychoanalytic perspective – Unconscious processes Copyright © 2006 Pearson Education Canada Inc. 17 Typical Symptoms Dissociative Identity Disorder (DID) – – Depersonalization Disorder – formally called Multiple Personality Disorder 2+ personalities in the same individual out-of-body experiences Dissociative Amnesia – impaired memory of psychogenic origin Copyright © 2006 Pearson Education Canada Inc. 18 DID Controversies problem of self-report reliability of recovered memories – – infantile amnesia scientific evidence for false memories Copyright © 2006 Pearson Education Canada Inc. 19 Quote of the Day “Well, this has been kind of fun, but I really must go. I’m conducting a seminar for multiple personality disorders, and it takes me forever to fill out the name tags.” Dr. Niles Crane Copyright © 2006 Pearson Education Canada Inc. 20 Skepticism regarding DID most diagnoses by a small number of advocates increased diagnoses following release of Sybil increasing number of personalities in DID cases why only in North America? Copyright © 2006 Pearson Education Canada Inc. 21 Etiology Psychological factors – – – Biological factors – recurring childhood trauma self-hypnosis state dependant learning genetic (conflicting research findings) Social factors – Social role theory Copyright © 2006 Pearson Education Canada Inc. 22 Spanos’ Theory of DID not a true “disorder” patients are role-playing – symptoms are iatrogenic Copyright © 2006 Pearson Education Canada Inc. 23 Treatment of Dissociative Disorders Psychological approach – recovery of traumatic memories – hypnosis main objective: integration of personalities Medical approach – distress reduction Copyright © 2006 Pearson Education Canada Inc. 24 Somatoform Disorders Problems featuring physical symptoms with no organic basis perhaps best interpreted from a psychoanalytic perspective symptoms not faked – unconscious factors – Copyright © 2006 Pearson Education Canada Inc. 25 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) Copyright © 2006 Pearson Education Canada Inc. 26 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 Copyright © 2006 Pearson Education Canada Inc. 27 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. Copyright © 2006 Pearson Education Canada Inc. 28 5 types of somatoform disorders 2) Somatization Disorder referred to at Briquet’s syndrome patient complains of at least 8 symptoms clinical presentation – – histrionic la belle indifference Copyright © 2006 Pearson Education Canada Inc. 29 5 types of somatoform disorders 3) Hypochondriasis belief that one has a serious disease (e.g., brain cancer) minimum 6 month duration “doctor shopping” Copyright © 2006 Pearson Education Canada Inc. 30 5 types of somatoform disorders 4) Pain Disorder preoccupation with pain symptoms complaints seem obsessive no known biological origin Copyright © 2006 Pearson Education Canada Inc. 31 5 types of somatoform disorders 5) Body preoccupation with an imagined physical defect common complaints: – Dysmorphic Disorder nose, mouth, ears common result: – unnecessary plastic surgeries Copyright © 2006 Pearson Education Canada Inc. 32 Diagnosing Somatoform Disorders First rule out intentional deception – Malingering Feigning – condition for external gain Factitious Disorder Intentionally feigning condition Copyright © 2006 Pearson Education Canada Inc. 33 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! Copyright © 2006 Pearson Education Canada Inc. 34 Etiology Biological factors – Psychological factors – – possibility of misdiagnosis imagined or real trauma secondary gain Social factors – culturally-specific anxiety Copyright © 2006 Pearson Education Canada Inc. 35 Treatment of Somatoform Disorders Traditionally, little empirical testing Cognitive-behavioural approach – Pain Disorder: reward successful coping Medical approach – antidepressants need for physician empathy Copyright © 2006 Pearson Education Canada Inc. 36