Transcript comer9e_handoutslides_ch06x

Chapter 6
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Disorders of Trauma and Stress
Stress, Coping, and the Anxiety Response
• The state of stress has two components:
– _____________ – event that creates demands
– _____________ – person's reactions to the demands
– People who sense that they have the ability and resources to
cope are more likely to take stressors in stride and respond well
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Influenced by how we judge both the event and our capacity
to react to the event effectively
Stress, Coping, and the Anxiety Response
• Stress reactions, and the fear they produce, are
often at play in psychological disorders
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• When we view a stressor as threatening, the
natural reaction is arousal and fear
Stress, Coping, and the Anxiety Response
• Stress and psychological disorders
• Stress and physical (psychophysiological)
disorders
– These disorders are listed in the DSM-5 under
“psychological factors affecting medical condition”
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– Acute stress disorder
– Posttraumatic stress disorder (PTSD)
– The DSM-5 lists these as “trauma and stressorrelated disorders”
Stress and Arousal: The Fight-or-Flight
Response
• The features of arousal and fear are set in
motion by the hypothalamus
– Two important systems are activated:
– An extensive network of nerve fibers that connect the central
nervous system (the brain and spinal cord) to all other organs
of the body
• Endocrine system
– A network of glands throughout the body that release hormones
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Autonomic nervous system (ANS)
Stress and Arousal: The Fight-or-Flight
Response
– Sympathetic nervous system pathway
– Hypothalamic-pituitary-adrenal pathway
• Hypothalamus signals the pituitary gland, which stimulates
the adrenal cortex to release corticosteroids – stress
hormones – into the bloodstream
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• There are two pathways, or routes, by which the
ANS and the endocrine system produce arousal
and fear reactions:
The Psychological Stress Disorders
• Acute stress disorder
– Symptoms begin within four weeks of event and last
for less than one month
– Symptoms may begin either shortly after the event, or
months or years afterward
• As many as 80% of all cases of acute stress disorder
develop into PTSD
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• Posttraumatic stress disorder (PTSD)
The Psychological Stress Disorders
–
–
–
–
Reexperiencing the traumatic event
Avoidance
Reduced responsiveness
Increased arousal, anxiety, and guilt
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• Aside from the differences in onset and duration,
the symptoms of acute stress disorders and
PTSD are almost identical:
• Can occur at any age and affect all aspects of life
• At least 3.5% of people in the U.S. are affected each
year
• Around two-thirds seek treatment at some point
• Ratio of women to men is 2:1
• In addition, people with low incomes are twice as
likely as people with higher incomes to experience
one of the stress disorders
• Some events – including combat, disasters, abuse,
and victimization – are more likely to cause
disorders than others
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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What Triggers Acute and Posttraumatic
Stress Disorders?
What Triggers Acute and Posttraumatic
Stress Disorders?
• Combat and stress disorders
• As many as 29% of Vietnam combat veterans
suffered acute or posttraumatic stress disorders
– An additional 22% had some stress symptoms
– 10% still experiencing problems
• A similar pattern is currently unfolding among
veterans of wars in Afghanistan and Iraq
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– Called “shell shock” or “combat fatigue”
– Post-Vietnam War clinicians discovered that soldiers
also experienced psychological distress after combat
What Triggers Acute and Posttraumatic
Stress Disorders?
• Disasters and stress disorders
• Types of disasters include earthquakes, floods, tornadoes,
fires, airplane crashes, and serious car accidents
• Because they occur more often, civilian traumas have been
implicated in stress disorders at least 10 times as often as
combat traumas
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– Acute or posttraumatic stress disorders may also
follow natural and accidental disasters
What Triggers Acute and Posttraumatic
Stress Disorders?
• Victimization and stress disorders
– People who have been abused or victimized often
experience lingering stress symptoms
• Terrorism and torture
– The experience of terrorism or the threat of terrorism
often leads to posttraumatic stress symptoms, as
does the experience of torture
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• Research suggests that more than one-third of all victims of
physical or sexual assault develop PTSD
• PTSD can sometimes be a factor in the
commission of crimes
• How much should juries and judges take a
defendant’s PTSD into consideration when
arriving at a verdict?
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Combat Trauma Takes the Stand
Why Do People Develop Acute and
Posttraumatic Stress Disorders?
• Clearly, extraordinary trauma can cause a stress
disorder
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– However, the event alone may not be the entire
explanation
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Why Do People Develop Acute and
Posttraumatic Stress Disorders?
• Biological and genetic factors
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– Traumatic events trigger physical changes in the brain
and body that may lead to severe stress reactions
and, in some cases, to stress disorders
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Why Do People Develop Acute and
Posttraumatic Stress Disorders?
• Personality factors
– Some studies suggest that people with certain
personalities, attitudes, and coping styles are
particularly likely to develop stress disorders
– Preexisting high anxiety
– Negative worldview
– A set of positive attitudes (called resiliency or
hardiness) is protective against developing stress
disorders
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• Risk factors include:
Why Do People Develop Acute and
Posttraumatic Stress Disorders?
• Childhood experiences
• An impoverished childhood
• Psychological disorders in the family
• The experience of assault, abuse, or catastrophe at an early
age
• Being younger than 10 years old when parents separated or
divorced
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– Researchers have found that certain childhood
experiences increase risk for later stress disorders
– Risk factors include:
Why Do People Develop Acute and
Posttraumatic Stress Disorders?
• Social support
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– People whose social support systems are weak are
more likely to develop a stress disorder after a
traumatic event
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Why Do People Develop Acute and
Posttraumatic Stress Disorders?
• Multicultural factors
• It seems that Hispanic Americans might be more vulnerable
to PTSD than other cultural groups
– Possible explanations include cultural beliefs systems about
trauma and the cultural emphasis on social relationships and
social support
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– There is a growing suspicion among clinical
researchers that the rates of PTSD may differ among
ethnic groups in the US
Why Do People Develop Acute and
Posttraumatic Stress Disorders?
• Severity of the trauma
• Especially risky: Mutilation and severe injury; witnessing the
injury or death of others
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– Generally, the more severe the trauma and the more
direct one's exposure to it, the greater the likelihood
of developing a stress disorder
How Do Clinicians Treat Acute and
Posttraumatic Stress Disorders?
– General goals:
• End lingering stress reactions
• Gain perspective on painful experiences
• Return to constructive living
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• About half of all cases of PTSD improve within 6
months; the remainder may persist for years
• Treatment procedures vary depending on type of
trauma
How Do Clinicians Treat Acute and
Posttraumatic Stress Disorders?
• Treatment for combat veterans
– Drug therapy
• Antianxiety and antidepressant medications are most common
• Reduce specific symptoms, increase overall adjustment
• Use flooding and relaxation training
• Use eye movement desensitization and reprocessing (EMDR)
– Insight therapy
• Bring out deep-seated feelings, create acceptance, lessen guilt
– Often use couple, family, or group therapy formats; rap
groups
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– Behavioral exposure techniques
• Exposure-based therapy may be the single most
helpful intervention for people with PTSD
• In virtual reality therapy, PTSD clients use
wraparound goggles and joysticks to navigate
their way through a computer-generated military
convoy, battle, or bomb attack in a landscape
that looks like Iraq or Afghanistan.
• Can you design a virtual reality exposure
treatment program for people with social anxiety
disorder?
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Virtual Reality Therapy: Better than the Real
Thing?
How Do Clinicians Treat Acute and
Posttraumatic Stress Disorders?
• Psychological debriefing
– A form of crisis intervention that has victims of trauma
talk extensively about their feelings and reactions
within days of the critical incident
–
–
–
–
Normalize responses to the disaster
Encourage expressions of anxiety, anger, and frustration
Teach self-help skills
Provide referrals
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• Four-stage approach:
Dissociative Disorders
– Our recall of past experiences helps us to react to
present events and guides us in making decisions
about the future
– People sometimes experience a major disruption of
their memory:
• They may not remember new information
• They may not remember old information
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• The key to our identity – the sense of
who we are and where we fit in our environment
– is memory
Dissociative Disorders
– In such disorders, one part of the person's memory
typically seems to be dissociated, or separated, from
the rest
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• When such changes in memory lack a clear
physical cause, they are called “dissociative”
disorders
Dissociative Disorders
– Dissociative amnesia
– Dissociative fugue
– Dissociative identity disorder (multiple personality
disorder)
– Depersonalization-derealization disorder
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• Types of dissociative disorders include:
Dissociative Amnesia
– The loss of memory is much more extensive than
normal forgetting and is not caused by physical
factors
– Often an episode of amnesia is directly triggered by a
specific upsetting event
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• People with dissociative amnesia are unable to
recall important information, usually of an
upsetting nature, about their lives
Dissociative Amnesia
– Localized – most common type; loss of all memory of
events occurring within a limited period
– Selective – loss of memory for some, but not all,
events occurring within a period
– Generalized – loss of memory beginning with an
event, but extending back in time; may lose sense of
identity; may fail to recognize family and friends
– Continuous – forgetting continues into the future;
quite rare in cases of dissociative amnesia
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Dissociative amnesia may be:
Dissociative Fugue
– For some, the fugue is brief – a matter of hours or
days – and ends suddenly
– For others, the fugue is more severe: people may
travel far from home, take a new name and establish
new relationships, and even a new line of work; some
display new personality characteristics
• Fugues tend to end abruptly
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• People with dissociative fugue not only forget
their personal identities and details of their past,
but also flee to an entirely different location
Dissociative Identity Disorder (Multiple
Personality Disorder)
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• A person with dissociative identity disorder (DID;
formerly multiple personality disorder) develops
two or more distinct personalities
(subpersonalities) each with a unique set of
memories, behaviors, thoughts, and emotions
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Dissociative Identity Disorder (Multiple
Personality Disorder)
• At any given time, one of the subpersonalities
dominates the person's functioning
• Most cases are first diagnosed in late adolescence
or early adulthood
– Symptoms generally begin in childhood after episodes of
abuse
• Typical onset is before age 5
• Women receive the diagnosis three times as often
as men
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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– Usually one of these subpersonalities – called the primary,
or host, personality – appears more often than the others
– The transition from one subpersonality to the next
(“switching”) is usually sudden and may be dramatic
How Do Subpersonalities Interact?
– Mutually amnesic relationships – subpersonalities
have no awareness of one another
– Mutually cognizant patterns – each subpersonality is
well aware of the rest
– One-way amnesic relationships – most common
pattern; some personalities are aware of others, but
the awareness is not mutual
• Those who are aware (“co-conscious subpersonalities”) are
“quiet observers”
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Generally there are three kinds of relationships:
How Do Subpersonalities Interact?
• Investigators used to believe that most cases of
the disorder involved two or three
subpersonalities
• There have been cases of more than 100
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– Studies now suggest that the average number is
much higher – 15 for women, 8 for men
How Do Subpersonalities Differ?
• Subpersonalities often display dramatically different
characteristics, including:
– Identifying features
• Subpersonalities may differ in features as basic as age, sex,
race, and family history
• Although encyclopedic information is not usually affected by
dissociative amnesia or fugue, in DID it is often disturbed
• It is not uncommon for different subpersonalities to have
different abilities, including being able to drive, speak a foreign
language, or play an instrument
– Physiological responses
• Researchers have discovered that subpersonalities may have
physiological differences, such as differences in autonomic
nervous system activity, blood pressure levels, and allergies
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– Abilities and preferences
Dissociative Identity Disorder (Multiple
Personality Disorder)
– Traditionally, DID was believed to be rare
– The number of people diagnosed with the disorder has
been increasing
– Although the disorder is still uncommon, thousands of
cases have been documented in the U.S. and Canada
alone
• Two factors may account for this increase:
– A growing number of clinicians believe that the disorder does exist
and are willing to diagnose it
– Diagnostic procedures have become more accurate
– Despite changes, many clinicians continue to question the
legitimacy of this category
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• How common is DID?
How Do Theorists Explain Dissociative
Amnesia and Dissociative Identity Disorder?
– Older explanations have not received much
investigation
– Newer viewpoints, which combine cognitive,
behavioral, and biological principles, have captured
the interest of clinical scientists
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• A variety of theories have been proposed to
explain dissociative disorders
How Do Theorists Explain Dissociative
Amnesia and Dissociative Identity Disorder?
• The psychodynamic view
• People fight off anxiety by unconsciously preventing painful
memories, thoughts, or impulses from reaching awareness
– In this view, dissociative amnesia and fugue are
single episodes of massive repression
– DID is thought to result from a lifetime of excessive
repression, motivated by very traumatic childhood
events
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– Psychodynamic theorists believe that dissociative
disorders are caused by repression, the most basic
ego defense mechanism
How Do Theorists Explain Dissociative
Amnesia and Dissociative Identity Disorder?
• The psychodynamic view
• Some individuals with DID do not seem to have these
experiences of abuse
• Further, why might only a small fraction of abused children
develop this disorder?
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– Most of the support for this model is drawn from case
histories, which report brutal childhood experiences,
yet:
How Do Theorists Explain Dissociative
Amnesia and Dissociative Identity Disorder?
• The behavioral view
• Momentary forgetting of trauma leads to a drop in anxiety,
which increases the likelihood of future forgetting
• Like psychodynamic theorists, behaviorists see dissociation
as escape behavior
– Also like psychodynamic theorists, behaviorists rely
largely on case histories to support their view of
dissociative disorders
• Moreover, these explanations fail to explain all aspects of
these disorders
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– Behaviorists believe that dissociation grows from
normal memory processes and is a response learned
through operant conditioning:
How Do Theorists Explain Dissociative
Amnesia and Dissociative Identity Disorder?
• State-dependent learning
• This link between state and recall is called state-dependent
learning
• This model has been demonstrated with substances and
mood and may be linked to arousal levels
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– If people learn something when they are in a
particular state of mind, they are likely to remember it
best when they are in the same condition
How Do Theorists Explain Dissociative
Amnesia and Dissociative Identity Disorder?
– People who are prone to develop dissociative
disorders may have state-to-memory links that are
unusually rigid and narrow; each thought, memory,
and skill is tied exclusively to a particular state of
arousal, so that they recall a given event only when
they experience an arousal state almost identical to
the state in which the memory was first acquired
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• State-dependent learning
How Do Theorists Explain Dissociative
Amnesia and Dissociative Identity Disorder?
• Self-hypnosis
• Called “hypnotic amnesia,” this phenomenon has been
demonstrated in research studies with word lists
• The parallels between hypnotic amnesia and dissociative
disorders are striking and have led researchers to conclude
that dissociative disorders may be a form of self-hypnosis
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– Although hypnosis can help people remember events
that occurred and were forgotten years ago, it can
also help people forget facts, events, and their
personal identity
How Are Dissociative Amnesia and
Dissociative Identity Disorder Treated?
• People with dissociative amnesia and fugue
often recover on their own
• In contrast, people with DID usually require
treatment to regain their lost memories and
develop an integrated personality
– Treatment for dissociative amnesia and fugue tends
to be more successful than treatment for DID
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– Only sometimes do their memory problems linger and
require treatment
How Do Therapists Help People With
Dissociative Amnesia And Fugue?
– Psychodynamic therapists guide patients to search
their unconscious and bring forgotten experiences
into consciousness
– In hypnotic therapy, patients are hypnotized and
guided to recall forgotten events
– Sometimes intravenous injections of barbiturates are
used to help patients regain lost memories
• Often called “truth serums,” the key to the drugs' success is
their ability to calm people and free their inhibitions
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• The leading treatments for these disorders are
psychodynamic therapy, hypnotic therapy, and
drug therapy
How Do Therapists Help Individuals With
DID?
• Unlike victims of dissociative amnesia or fugue,
people with DID do not typically recover without
treatment
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– Treatment for this pattern, like the disorder itself, is
complex and difficult
Abnormal Psychology | Ronald J. Comer | Ninth Edition
How Do Therapists Help Individuals With
DID?
– Once a diagnosis of DID has been made, therapists
try to bond with the primary personality and with each
of the subpersonalities
– As bonds are forged, therapists try to educate the
patients and help them recognize the nature of the
disorder
• Some use hypnosis or video as a means of presenting other
subpersonalities
– Many therapists recommend group or family therapy
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• Recognizing the disorder
How Do Therapists Help Individuals With
DID?
• Recovering memories
• These techniques tend to work slowly in cases of DID
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– To help patients recover missing memories, therapists
use many of the approaches applied in other
dissociative disorders, including psychodynamic
therapy, hypnotherapy, and drug treatment
How Do Therapists Help Individuals With
DID?
• Integrating the subpersonalities
• Many patients distrust this final treatment goal and their
subpersonalities see integration as a form of death
– Once the subpersonalities are integrated, further
therapy is typically needed to maintain the complete
personality and to teach social and coping skills to
prevent later dissociations
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– The final goal of therapy is to merge the different
subpersonalities into a single, integrated identity
– Integration is a continuous process; fusion is the final
merging
• DSM-5 categorizes depersonalizationderealization disorder as a dissociative disorder,
even though it is not characterized by the
memory difficulties found in the other
dissociative disorders
• Its central symptom is persistent and recurrent
episodes of depersonalization (the sense that
one’s own mental functioning or body are unreal
or detached) and/or derealization (the sense that
one’s surroundings are unreal or detached)
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Depersonalization-Derealization Disorder
Depersonalization-Derealization Disorder
• People with this disorder feel as though they have
become separated from their body and are
observing themselves from outside
• Depersonalization experiences by themselves do
not indicate a depersonalization disorder
– Transient depersonalization reactions are fairly common
– The symptoms of a depersonalization disorder are
persistent or recurrent, cause considerable distress, and
interfere with social relationships and job performance
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– This sense of unreality can extend to other sensory
experiences and behavior
Depersonalization-Derealization Disorder
• The disorder occurs most frequently in
adolescents and young adults, hardly ever in
people older than 40
• Few theories have been offered to explain the
disorder and little research has been conducted
on the problem
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– The disorder comes on suddenly and tends to be
long-lasting