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.

Reexperiencing AvoidanceRepeated,

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 anxiety Dissociative symptomsPredicts a worse

prognosisHypervigilanceRestlessness,

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 PTSDEMDR (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 DisordersBiological 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 modelconsciouspreconsciousunconscious

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 DISORDERSDiagnosis 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 disorder

Malingering 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 DISORDERSFrequency 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 DISORDERSCauses 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 7-6Psychological 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.