1Trauma and Stress Related Disorders

Trauma and Stress Related Disorders

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⦿ Post Traumatic Stress Disorder

⦿ Acute Stress Disorder

Posttraumatic Stress Disorder (PTSD)⦿ The person exposed to actual or threatened death, serious

injury or violence: ⦿ experiencing the event ⦿ witnessing the event ⦿ learning that a violent or accidental death or threat of

death to a close other ⦿ experiencing repeated or extreme exposure to

aversive details of event other than media reports

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PTSD⦿ Four categories of symptoms: • Re-experiencing the traumatic event ➡Nightmares, intrusive thoughts, or images

• Avoidance of stimuli ➡Refuse to walk on street where rape occurred

• Other signs of mood and cognitive changes ➡Memory loss, negative thoughts and emotions, self-blame, blaming

others, withdrawal • Increased arousal and reactivity ➡Irritability, aggressiveness, recklessness or self-destructiveness,

insomnia, difficulty concentrating, hypervigilance, exaggerated startle response

⦿ Tends to be chronic (at least 1 month) ⦿ High risk of suicide and self-injuries, illness

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Acute Stress Disorder⦿ The person exposed to actual or threatened death, serious

injury or violence: ⦿ experiencing the event ⦿ witnessing the event ⦿ learning that a violent or accidental death or threat of

death to a close other ⦿ experiencing repeated or extreme exposure to

aversive details of event other than media reports

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Acute Stress Disorder9 of the following symptoms 3 to 31 days: ⦿ Intrusive distressing memories ⦿ Distressing dreams ⦿ Flashback ⦿ Prolonged stress for reminders ⦿ In ability to experience positive events ⦿ Avoid reminders ⦿ Sleep disturbance ⦿ Hypervigilance ⦿ Irritability ⦿ Startle response ⦿ Agitation, restlessness ⦿ Problems with concentration

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Etiology of PTSD⦿ Common risk factors with other anxiety disorders

• Genetic, overactive amygdala, • childhood exposure to trauma, • Selective attention, • neuroticism/negative affectivity • Two-factor model of conditioning also applicable

⦿ Unique factors • Severity and type of trauma • Neurobiological ● Smaller hippocampal volume linked to PTSD

• Avoidance coping, dissociation, memory suppression • Intelligence, social support, and ability to grow from the experience

enhance coping

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Psychological Treatment of PTSD⦿ Exposure to memories and reminders of the original

trauma •Either direct (in vivo) or imaginal •Virtual reality (VR) effective

⦿ Cognitive therapy •Enhance beliefs about coping abilities

⦿ Treatment of ASD may prevent PTSD •Shows benefits even 5 years after the traumatic event

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Dissociative Disorders

Dissociative Disorders⦿ Dissociation

•Some aspect of cognition or experience becomes inaccessible to consciousness, self awareness.

⦿ Sudden disruption in the continuity of: •Consciousness •Emotions •Motivation •Memory •Identity

Dissociative Disorders⦿ Three major categories

•Dissociative Amnesia •Depersonalization/Derealization disorder •Dissociative Identity Disorder

๏Prevalance 1 in a 1000 (Mezzich, Fabrega et al., 1989)

DSM-5 Criteria for Dissociative Amnesia⦿ Inability to remember important personal information, usually of a

traumatic or stressful nature, that is too extensive to be ordinary forgetfulness

⦿ The amnesia is not explained by substances, or by other medical or psychological conditions

⦿ Specify dissociative fugue subtype if: • the amnesia includes inability to recall one’s past, confusion about identity, or

assumption of a new identity, and • sudden, unexpected travel away from home or work

Dissociative Amnesia⦿ Inability to remember important personal information

⦿ Usually info about a traumatic or stressful event ⦿ Too extensive to be ordinary forgetfulness ⦿ The amnesia is not explained by substances, or by other medical or

psychological condition ⦿ May last as a short period, several hours or years

Dissociative Amnesia: Dissociative Fugue⦿ Amnesia and flight and new identity

•Latin fugere, “to flee” ⦿ Sudden, unexpected travel with inability to recall one’s

past •Assume new identity ●May involve new name, job, personality characteristics

•More often of brief duration •Remits spontaneously

“Z'nin 1 hafta önce okula giderken başına vurularak darp edildiği, çantası, montu ve atkısının çalındığı öğrenildi. Bu olay sonrasında, Z olayın olduğu yerden geçerken ağlayacak gibi olduğunu, olayın sürekli aklına geldiğini ve okula gitmek istemediği belirtti. Yapılan bu ilk görüşmede ______________ tanısı düşünüldü. Z, tedavisinden 3 hafta sonra yakınmalarının azaldığını ve yeniden yalnız başına okula gidebildiği ancak bu sırada kimseye açıklayamadığı bir olay yaşadığını söyledi. Z, okula gitmek için evden çıktığını, sonrasında kendini tanımadığı bir yerde, bir binanın duvarının dibine uzanmış halde bulduğunu ve oradaki insanlara nerede olduğunu sorduğunda Batman'da olduğunu öğrendiğini, Kocaeli'den oraya nasıl gittiğini hatırlamadığını, bir süre sonra aklına Siirt'te yaşayan ablasını yanına gitmek geldiğini, otobüs şoförüne parasını kaybettiğini söylediğini ve Siirt'e kadar kendisini götürmesi için rica ettiğini, ablasının kendisini gördüğünde çok şaşırdığını söyledi.”

Memory Deficits and Dissociation⦿ Memory deficits in explicit but not implicit memory ⦿ Explicit memory

•Involves conscious recall of experiences ●e.g., senior prom, mom’s birthday party

⦿ Implicit memory •Underlies behaviors based on experiences that cannot be

consciously recalled ●e.g., playing tennis, writing a check Eg. When passing the the location of incident getting terrified (implicit)

Memory Deficits and Dissociation⦿ Distinguishing other causes of memory loss from dissociation:

•Dementia ●Memory fails slowly over time ●Is not linked to stress ●Accompanied by other cognitive deficits ●Inability to learn new information

•Memory loss after a brain injury •Substance abuse

Depersonalization/Derealization Disorder⦿ Perception of self is altered

•Triggered by stress or traumatic event •No disturbance in memory •No psychosis or loss of memory •Often comorbid with anxiety, depression •Typical onset in adolescence •Childhood trauma is reported often •Chronic course

⦿ Symptoms are not explained by substances, another dissociative disorder, another psychological disorder, or a medical condition

Depersonalization/Derealization Disorder⦿ Depersonalization

•Unusual sensory experiences ●Limbs feel deformed or enlarged ●Voice sounds different or distant

•Feelings of detachment or disconnection ●Watching self from outside

⦿ Derealization •World has become unreal ●World appears strange, peculiar, foreign, dream-like ●Objects appear at times strangely diminished in size, at times flat ●Incapable of experiencing emotions ●Feeling as if they were dead, lifeless, mere automatons ●Experiences of unreality of surroundings

⦿ Symptoms are persistent or recurrent / Reality testing remains intact

The world appears strange, foreign, dreamlike…Objects appear diminish in size… Sound appear to come from

distance… Experiencing neither pain nor pleasure… As if you are dead, lifeless, robotic…

Dissociative Identity Disorder (DID)⦿ Two or more distinct and fully developed personalities (alters)

•Each has unique modes of being, thinking, feeling, acting, memories, and relationships

•Primary alter may be unaware of existence of other alters ⦿ Most severe of dissociative disorders

•Recovery may be less complete ⦿ Typical onset in childhood ⦿ More common in women than men ⦿ Often comorbid with:

•PTSD, major depression, somatic symptoms ⦿ Has no relation to schizophrenia

•No thought disorders or behavioral disorganization

DSM-5 Criteria Dissociative Identity Disorder⦿ This disruption may be observed by others or reported by the patient

⦿ Recurrent gaps in recalling events or important personal information that are beyond ordinary forgetting

⦿ Symptoms are not part of a broadly accepted cultural or religious practice, and are not due to drugs or a medical condition

⦿ In children, symptoms are not better explained by an imaginary playmate or by fantasy play

Dissociative Identity Disorder⦿ Epidemiology

•No identified reports of DID or dissociative amnesia before 1800 (Pope et al., 2006)

•(1890-1920)77 cases are reported •Major increases in rates since 1970s •In 1990 1.3% in Winnipeg, Canada •In 1999 0.4% in Sivas, Turkey

⦿ Appearance of DID in popular culture • Sybil (16 personalities) • The Three Faces of Eve •Book and movie received much attention

Etiology of DID: Two Major Theories

⦿ Posttraumatic Model •DID results from severe psychological and/or sexual abuse in

childhood

⦿ Sociocognitive Model •DID a form of role-play in suggestible individuals ●Occurs in response to prompting by therapists or media ●No conscious deception

Suggestion of the Therapist⦿ T: Have you ever drive and arrive at your destination

without remembering how you got there?

⦿ P: Yes,

⦿ T: Well, the alter took you there.

Suggestion of the Therapist⦿ T: Have you ever experience internal arguments in your

head or voices in your head

⦿ P: Yes, I tell turn right, but a voice tell turn left.

⦿ T: Well, your alters are fighting in your head.

Ethical DilemmaRocovered memories may be as a result of popular writings

and therapist’s suggestions

??? Applying recovered memories in courts ???

Treatment of Dissociative Identity Disorder

⦿ Most treatments involve: •Empathic and supportive therapist •Integration of alters into one fully functioning individual •Improvement of coping skills for stress

⦿ Psychodynamic approach adds: •Overcome repression •Use of hypnosis ●Age regression ●Can actually worsen symptoms