Post-Traumatic Stress Disorders, Dissociative and Somatoform Disorders

Chapter 7

Overview

Dissociation (def)-the disruption of the normally integrated mental processes involved in memory or consciousness.

Stress Disorders

– Acute Stress Disorder (ASD)-short term reaction to trauma, characterized by symptoms of dissociation, re-experiencing avoidance, and increases anxiety or arousal.

– Post Traumatic Stress Disorder (PTSD)-characterized by persistent, maladaptive disruptions in the integration of memory, consciousness, or identity.

Dissociative Disorders

– Dissociative Fugue-characterized by sudden and unexpected travel away from home, and an inability to recall the past, as well as confusion as to one’s identity or the assumption of a new identity.

– Dissociative Amnesia-Sudden inability to recall extensive and important personal information that exceeds normal forgetfulness.

– Dissociative Identity Disorder (DID) aka MPD- characterized by the existence of two or more distinct personalities in a single individual

Somatization Disorder

– Hypochondriasis-belief that the individual is suffering from a physical illness.

– Pain Disorder-characterized by a preoccupation with pain.

– Body Dsymorphic disorder-patient is pre-occupied with some imagined defect in appearancetypically a facial feature

Traumatic Stress

(def)-DSM IV –event that involves actual or threatened death to self or others, creating feelings of intense fear, helplessness or horror.

Both survivors and witnesses are expected to be greatly distressed as part of their normal response to traumatic stress.

Acute and Post traumatic Stress Disorders: Symptoms and Features

Major Difference is Duration.– ASD-develops within 4 weeks– Delayed

Both characterized by several similar features:

Flashbacks-re-experiencing or “reliving” the trauma Marked avoidance of stimuli associated with the

trauma Persistent arousal or anxiety

Dissociative Symptoms (ASD)

– Depersonalization-report feeling dazed or spaced out..

– De-realization-marked sense of unreality about self or environment.

– Dissociative amnesia-inability to recall certain aspects of the experience.

Etiology

Social Factors– PTSD more likely to develop as a result of

rape or combat, especially if the person suffered physical harm.

– Social support-lack of support is a strong predictor in the development of both ASD and PTSD

Etiology

Biological Factors– Family history of mental disorders– Women and minorities

Etiology

Psychological Factors– Two Factor theoryCombination of Classical

and Operant Conditioning– Cognitive Factors

Expectancy Preparedness Control

– Emotional Processing

Essential Elements for Successful Emotional Processing

Victim must find a way to be emotionally engaged with the memory.

Victims must be able to talk about the experience

Victims must learn to develop a balanced view of the world againmeaning making-in the process of integrating the trauma into their belief system and memories people often find some higher value for enduring the trauma

Biological Consequences of Exposure

– Alterations of function and structure of the amygdale and hippocampus associated with increased fear reactivity and intrusive memories following a traumatic event.

– Increased levels of general arousal such as a higher resting heart rate and increased levels of NEsuggest the sensitization of the sympathetic nervous system and heightened fear response and reactivity.

– Possible explanations include a failure of the stress response system and continued activation of the Hypothalamic Pituitary Axis.

– People with PTSD show lower levels of cortisol instead of higher as anticipated, indicating that the stress response activated by the stressful event is not turned off in people with PTSD.

Prevention and Treatment

Interventions Critical Incident Stress (CIS) Emergency Treatment of Trauma Victims. Critical Incident Stress De-briefing.

Treatment of ASD

Based on Cognitive Behavior Therapy First, establish a trusting therapeutic relationship. Provide education abut the process of coping with trauma Stress Management Training Encourage Re-experience of the trauma Integrating the traumatic event into the individual’s

experience.

Treatment of PTSD

Cognitive Behavioral Therapy-same as ASD, but longer in duration.

Anti-depressant therapy-recently approved Re-exposure to the traumatic event Imagery Rehearsal therapy Eye Movement Desensitization

Dissociative Disorders

Controversy as to the extent to which these disorders exist

Unconscious processes do exist and they play a role in both normal and abnormal cognition.

Classification (DSM-IV-TR)

Dissociative Fugue-purposeful travel away from home, accompanied by confusion of identity and memory loss as a response to the trauma.

Dissociative Amnesia-sudden inability to recall extensive personal information.

Depersonalization-less dramatic problem characterized by severe and persistent feelings of being detached from onesself.

Classification

Dissociative Identity Disorder (DID)-rare disorder characterized by the existence of two or more distinct personalities in a single individual.

At least two of the personalities (alters) repeatedly take control of the person’s behavior.

Individual is unable to remember events or information when the other personalities are in control.

Original Personality may or may not be aware of the alters.

DID: Disorder or Not?

Two Extremes of the debate Reasons for Skepticism

– Frequency of diagnosis increased significantly after the release of the book and movie Sybil.

– Number of personalities co-existing in an individual has gone from 3-4 to more than 100.

– DID rarely diagnosed outside the US and Canada Cases of Malingering: Kenneth Bianchi

Psychological Factors of Dissociative Disorders

Dissociative fugue, amnesia and depersonalization can usually be traced to a specific traumatic experience.

Association between trauma and DID is much less clear.

Theories of Psychological Factors related to DID

Early Child Abuse Abuse overwhelms a child’s psychological defense

mechanisms, and with continued abuse, dissociation becomes a means of coping.

Problem: case studies that report abuse are based on patient’s memories and clinicians evaluations. These are not objective assessments of the past as memories may be selectively recalled, distorted, or created to conform with subsequent experiences.

Biological Factors

Twin Studies have found no genetic contribution to dissociative symptoms and suggest it is a factor of shared family environment.

There may be indications that there are biological causes not yet discovered due to the development of similar symptoms due to drug abuse and aging.

Social Factors

Iatrogenesis-the manufacture of the dissociative disorder by the treatment.

Expectation and leading questions of the therapist.

Diagnosis of DID in Turkey

Treatment of Dissociative Disorders

Uncovering and recounting the past traumatic events.

Hypnosis Medication to reduce distress Treatment for DIDintegration of personalities Effectiveness of treatment

Somatoform Disorders

Patient does feel pain as the problem is real in the mind of the patient.

Can be very dramatic such as blindness and paralysis.

More often the person suffers from numerous complaints such as stomach upset, chronic pain and dizziness.

Some types of somatoform disorders are defined by a preoccupation with a particular body part or with fears about a particular illness.

Classification

Conversion Disorder -central assumption that psychological conflicts are converted into physical symptoms

Somatization Disorder -(more common) characterized by a history of multiple physical complaints in the absence of a physical cause.

Hypochondriasis - fear or belief that one is suffering from a physical illness worries must last at least 6 months and medical evaluations do not alleviate the fear of the disease.

Pain Disorder - complaints seem excessive and are motivated at least in part by psychological factors such as the attention the illness brings them.

Body Dysmorphic Disorder - preoccupation with some imagined defect that far exceeds normal worries about physical imperfection.

Malingering and Factitious Disorder

Malingering-pretending to have a somatoform disorder to achieve some external gain such as disability payment.

Factitious Disorder-unlike malingering, although the condition is also faked, the motivation is a desire to assume the sick role. Repetitive patter of the disorder is called Munchhausen Syndrome

Biological Factors

None Diagnosis by exclusion

Psychological Factors

Lack of Research Traumatic Stress appears to be a factor Hypervigilance

Social Factors

Limited insight into their emotional distress Lack of tolerance of psychological complaints

Treatment

Cognitive Behavioral Therapy Anti-Depressant Medication

Case Study: Sarah

14year old white female in the 8th grade Parents divorced lives with father Mother-alcoholic 18 year old step brother lives in household

Assessment:

Unstructured Diagnostic Interview Psychiatric Evaluation Consultation with School Counselors

Background

Referred by school counselor due to falling asleep in class and skipping school

Lying-when asked why she was falling asleep she claimed to have a part time job.

Possible substance abuse behavior-admitted to extensive partying, passing out and sometimes sleeping on the street.

Nightmares and sleeping problems. Forced to comply with therapy by Father and school Father initially protested confidentiality issues as he

thought he should be allowed in sessions.

Symptoms

Nightmares Detachment from sexual encountersselling

body for alcohol Lack of self –esteem Trouble concentrating Substance Abuse

Diagnosis

Post traumatic Stress Disorder-chronic, delayed onset

Dsythymic Disorder-early onset Alcohol Abuse

DSM-IV-TR

Axis one: Axis Two: Axis Three Axis Four: Axis Five:

Treatment

Family Therapy with Father Individual Therapy Re-exposure Therapy Rational Emotive Therapy

Prognosis:

Gaurded High Risk for Relapse