Transcript Post-Traumatic Stress Disorders, Dissociative and

Post-Traumatic Stress Disorders,
Dissociative and Somatoform
Disorders
Chapter 7
Overview
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Dissociation (def)-the disruption of the
normally integrated mental processes
involved in memory or consciousness.
Stress Disorders
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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
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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 MPDcharacterized by the existence of two or more distinct
personalities in a single individual
Somatization Disorder
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Hypochondriasis-belief that the individual is
suffering from a physical illness.
Pain Disorder-characterized by a
preoccupation with pain.
Body Dsymorphic disorder-patient is preoccupied with some imagined defect in
appearancetypically a facial feature
Traumatic Stress
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(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
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Major Difference is Duration.
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ASD-develops within 4 weeks
Delayed
Both characterized by several similar
features:
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Flashbacks-re-experiencing or “reliving” the trauma
Marked avoidance of stimuli associated with the
trauma
Persistent arousal or anxiety
Dissociative Symptoms (ASD)
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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
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Social Factors
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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
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Biological Factors
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Family history of mental disorders
Women and minorities
Etiology
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Psychological Factors
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Two Factor theoryCombination of Classical
and Operant Conditioning
Cognitive Factors
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Expectancy
Preparedness
Control
Emotional Processing
Essential Elements for Successful
Emotional Processing
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Victim must find a way to be emotionally engaged
with the memory.
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Victims must be able to talk about the experience
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Victims must learn to develop a balanced view of the
world againmeaning 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
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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 NEsuggest 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
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Interventions
Critical Incident Stress (CIS)
Emergency Treatment of Trauma Victims.
Critical Incident Stress De-briefing.
Treatment of ASD
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Based on Cognitive Behavior Therapy
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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
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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
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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)
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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
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Dissociative Identity Disorder (DID)-rare disorder
characterized by the existence of two or more
distinct personalities in a single individual.
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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?
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Two Extremes of the debate
Reasons for Skepticism
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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
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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
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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
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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
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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
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Uncovering and recounting the past traumatic
events.
Hypnosis
Medication to reduce distress
Treatment for DIDintegration of personalities
Effectiveness of treatment
Somatoform Disorders
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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
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Conversion Disorder -central assumption that psychological conflicts are
converted into physical symptoms
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Somatization Disorder -(more common) characterized by a history of multiple
physical complaints in the absence of a physical cause.
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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.
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Pain Disorder - complaints seem excessive and are motivated at least in part by
psychological factors such as the attention the illness brings them.
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Body Dysmorphic Disorder - preoccupation with some imagined defect that far
exceeds normal worries about physical imperfection.
Malingering and Factitious Disorder
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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
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None
Diagnosis by exclusion
Psychological Factors
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Lack of Research
Traumatic Stress appears to be a factor
Hypervigilance
Social Factors
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Limited insight into their emotional distress
Lack of tolerance of psychological complaints
Treatment
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Cognitive Behavioral Therapy
Anti-Depressant Medication
Case Study: Sarah
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14year old white female in the 8th grade
Parents divorced lives with father
Mother-alcoholic
18 year old step brother lives in household
Assessment:
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Unstructured Diagnostic Interview
Psychiatric Evaluation
Consultation with School Counselors
Background
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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
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Nightmares
Detachment from sexual encountersselling
body for alcohol
Lack of self –esteem
Trouble concentrating
Substance Abuse
Diagnosis
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Post traumatic Stress Disorder-chronic,
delayed onset
Dsythymic Disorder-early onset
Alcohol Abuse
DSM-IV-TR
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Axis one:
Axis Two:
Axis Three
Axis Four:
Axis Five:
Treatment
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Family Therapy with Father
Individual Therapy
Re-exposure Therapy
Rational Emotive Therapy
Prognosis:
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Gaurded
High Risk for Relapse