Chapter 7: Acute & PTSD, Dissociative, & Somatoform Disorders

Chapter 7: Acute & PTSD, Dissociative,

& Somatoform Disorders

Fall, 2012

Dr. Mary L. Flett, Instructor

Overview

These disorders, while differing in many ways, share one common similarity: dissociation

Limited research on this area Conflicting theories and schools of belief Lack of empirical research; lots of anecdotal At the core – is the mind all powerful?

Acute & Post-traumatic Stress Disorders (PTSD)

Traumatic stress is defined as an event that involves actual or threatened death or serious injury to self or others, and creates intense feelings of fear, helplessness, or horror Rape Military combat Bombings Airplane crashes Earthquakes Fires Automobile wrecks


Acute stress disorder occurs within 4 weeks after the exposure and is characterized by: dissociative symptoms re-experiencing the event avoidance of reminders marked anxiety or arousal

PTSD the symptoms are longer lasting or delayed


Dissociative symptoms in PTSD include feeling dazed or spaced out a marked sense of unreality (derealization) the inability to recall important aspects of the

trauma (dissociative amnesia) numbing or detachment


Trauma is defined as the experience of an event involving actual or threatened

death or serious injury to self or others a response of intense fear, helplessness, or horror in

reaction to the event Different trauma may have unique psychological

consequences 9/11 experiences suggest those not directly exposed to

trauma suffered at least an acute stress response disaster & emergency workers are less likely to experience

stress response, but do need to attend to their own issues


Co-morbidity high for depression, other anxiety disorders, and alcohol abuse

Increased suicide risk Differential diagnosis between adjustment

disorder and ASD looks at “normal” reactions to painful stressors such as losing a job


Frequency of Trauma, PTSD, & ASD Traumatic stressors are common, not rare as

previously believed Women are especially likely to develop PTSD if

raped; men if in combat Children and women more vulnerable to PTSD Members of marginalized communities more likely

to experience PTSD Most common experience is sudden, unexpected

death of a loved one


Frequency of Trauma, PTSD, & ASD Risk is higher for those who engage in risky

behavior, have a history of conduct disorders, or are extroverts

Individuals who are “neurotic” (anxious and easily upset) more likely to develop PTSD

If previous trauma experienced, vulnerability to a second episode is higher

Family history of mental illness is also a predictor


Course & Outcome Best predictors of future PTSD

numbing depersonalization sense of reliving the experience

Sx generally diminish over time with greatest improvement seen within first year

Sx may remain, however, for as long as 40-50 years


Causes Social factors include degree of exposure Lack of support or denial of symptoms Environmental influence is higher than genetic Genes appear to contribute most strongly to

arousal/anxiety symptoms and least strongly to re-experiencing


Biological Effects of Exposure Consequences include

alterations in functioning and structure of the amygdala Sympathetic nervous system appears to be aroused and the

fear response sensitized in PTSD

No direct evidence of brain damage due to PTSD Damage may be pre-existing Brain trauma is not same as emotional response


Psychological Factors Two-Factor Theory states that classical

conditioning creates fears when paired; operant conditioning maintains avoidance by reducing fear

Avoidance prevents the extinction of anxiety through exposure

Dissociation may be an unconscious defense that helps cope with the trauma


Psychological Factors Emotional processing

victim must engage emotionally with the traumatic memory victim must find a way to articulate and organize their chaotic

experience victim must come to believe that, despite their experience, the

world is not a terrible place

Assuming all three steps are completed, victim may experience post-traumatic growth


Prevention & Treatment Offering immediate psychological help to victims

is a common goal Critical incident stress debriefing (CISD)

designed to intervene as closely to the event as possible if done correctly, may mitigate symptoms, but no evidence to

support assertion that CISD prevents PTSD if done poorly, may actually exacerbate symptoms

Returning to normal routine quickly appears to be beneficial, whether this is combat or work


Treatment of ASD not well researched; PTSD has received more study

Most effective treatment for PTSD is re-exposure to trauma confronting feared situations imagery rehearsal therapy prolonged exposure emotional processing & making meaning


Eye movement desensitization & reprocessing (EMDR) is another technique Has research validity Is as effective as prolonged exposure May be ineffective in hands of poorly trained

therapist

Dissociative Disorders

Dissociative disorders are characterized by persistent, maladaptive disruptions in the integration of memory, consciousness, or identity May be all “hooey” May be legitimate, and under reported May be rare


Hysteria & the Unconscious From the Greek for uterus (hystera); reflects

ancient view that a woman’s desire to have a baby, when frustrated, cause these symptoms

Freud (Charcot & Janet) all believed that hysteria could be treated by hypnosis Freud considered dissociation from reality to be a normal

process; an expression of unconscious conflict Janet believed it was a pathological process Freud had better media exposure and his theory dominated


Current research on “the unconscious” Explanations include

rational and experiential systems (Epstein) implicit and explicit memory (Schacter)

Hypnosis & altered states of consciousness Suggestibility? Dissociative experience?


Symptoms of Dissociative Disorders Depersonalization Psychogenic amnesia

inability to recall events, persons, or emotions associated with a trauma

Dissociative Fugue sudden, unplanned travel, the inability to remember details

about the past, and confusion about identity or the assumption of a new identity

Recovered memory


Diagnosis of Dissociative Disorders Four subtypes found in DSM

Dissociative fugue (travel away from home; inability to recall) Dissociative amnesia (sudden inability to recall extensive &

important personal information) Depersonalization disorder (feelings of being detached from

self) Dissociative Identity Disorder (DID) (existence of two or more

“personalities” within one individual


Frequency of Dissociative Disorders Dominant thinking is that these are very, very rare Minority thinking makes a strong case that

individuals are mis-diagnosed (schizophrenics, BPD, et al) and not being treated

Other explanations include role enactment


Causes Psychological Factors

precipitated by a traumatic experience state-dependent learning

Biological Factors Little evidence has been gathered

Social Factors iatrogenesis – the manufacture of a disorder by its treatment


Treatment Focus is on uncovering and recounting traumatic

events assumes that if trauma can be expressed, need for

dissociative coping will disappear

Integrating all personalities into a single whole No systematic research on any one approach has

been collected

Somatoform Disorders

Symptoms Complaints about physical symptoms that are

“real”, but no medical evidence of the cause can be identified May involve substantial impairment of sensory or muscular

system (blindness or paralysis) Chronic pain, upset stomach, dizziness Preoccupation with a particular part of the body or fears of a

particular illness


Unnecessary medical treatment Primary care is point of access Difficult to evaluate objectively Result in unnecessary surgery and laboratory

testing May account for ½ of all ambulatory care costs


Diagnosis Five subcategories

Conversion Disorder (hysterical blindness; paralysis) Somatization Disorder (history of multiple somatic complaints

in the absence of organic impairments) histrionic la belle indifference

Hypochondriasis (fear of suffering from physical illness) Pain Disorder (preoccupation with pain) Body Dysmorphic Disorder (preoccupation with a particular

body part)


Diagnosis Malingering & Factitious Disorders

Not a psychological problem; intentional, conscious roles Motivated by desire to assume the sick role (factitious

disorder, aka Munchausen Syndrome) Pretending to be ill to achieve some external gain

(Malingering)


Frequency Lower prevalence today due to improved

diagnostic practices No longer hysteria; now possibly chronic fatigue

syndrome, Gulf War syndrome New category (multisomatoform disorder) is

proposed for DSM-V


Gender, SES, and Culture More common among women, particularly

somatization disorder More common among lower socio-economic

groups, and psychological unsophisticated individuals

Cultural implications arise where culture does not allow free expression of emotions, but does accept body pains


Co-morbidity Occur particularly with depression and anxiety Frequently linked to antisocial personality disorder

Usually found in different members of the family, not one individual


Causes Biological Factors

real potential for misdiagnosis diagnosis by exclusion Conversion disorder may resolve into a known physical

disorder (epilepsy, neurological disease)

Psychological Factors May be triggered by trauma, but not necessarily Extra attention; avoidance of undesirable activity Adopting the “sick role”


Causes Social Factors

Emotional expression of distress may be unacceptable


Treatment Operant approaches to chronic pain alter reward

system for “pain behavior” CBT uses cognitive restructuring to address

emotional and thought components of pain Anti-depressants are helpful Lack of research due to fact that primary care

physicians do most of treatment without partnering with psychologists Patients shop for sympathetic doctors to treat them adding

costs to care

Documents

Chapter 7: Acute & PTSD, Dissociative, & Somatoform Disorders