Disorders of Trauma and Stress

Disorders of Trauma and Stress
Chapter 6

Stress, Coping, and the Anxiety Response
The state of stress has two components: _____________ – event that creates demands _____________ – person's reactions to the demands Influenced by how we judge both the event and our capacity to react to the event effectively People who sense that they have the ability and resources to cope are more likely to take stressors in stride and respond well

When we view a stressor as threatening, the natural reaction is arousal and fear Stress reactions, and the fear they produce, are often at play in psychological disorders Fear is a “package” of responses that are physical, emotional, and cognitive People who experience a large number of stressful events are particularly vulnerable to the onset of anxiety and other psychological disorders

Stress and psychological disorders Acute stress disorder Posttraumatic stress disorder (PTSD) The DSM-5 lists these as “trauma and stressor-related disorders” Stress and physical (psychophysiological) disorders These disorders are listed in the DSM-5 under “psychological factors affecting medical condition”

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: Autonomic nervous system (ANS) 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

Stress and Arousal: The Fight-or-Flight Response
There are two pathways, or routes, by which the ANS and the endocrine system produce arousal and fear reactions: 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 When we face a dangerous situation, the hypothalamus first excites the sympathetic nervous system, which stimulates key organs either directly or indirectly When the perceived danger passes, the parasympathetic nervous system helps return body processes to normal The reactions on display in these two pathways are collectively referred to as the fight-or-flight response Each person has a particular pattern of autonomic and endocrine functioning and so a particular way of experiencing arousal and fear…

The Psychological Stress Disorders
Acute stress disorder Symptoms begin within four weeks of event and last for less than one month Posttraumatic stress disorder (PTSD) 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 During and immediately after trauma, we may temporarily experience levels of arousal, anxiety, and depression For some, symptoms persist well after the trauma These people may be suffering from: Acute stress disorder Posttraumatic stress disorder (PTSD) The precipitating event usually involves actual or threatened serious injury to self or others The situations that cause these disorders would be traumatic to anyone (unlike other anxiety disorders)

The Psychological Stress Disorders
Aside from the differences in onset and duration, the symptoms of acute stress disorders and PTSD are almost identical: Reexperiencing the traumatic event Avoidance Reduced responsiveness Increased arousal, anxiety, and guilt

What Triggers Acute and Posttraumatic Stress Disorders?
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 7–9% of people in the U.S. are affected sometime during their lifetime After trauma, around 20% of women and 8% of men develop disorders

Combat and stress disorders Called “shell shock” or “combat fatigue” Post-Vietnam War clinicians discovered that soldiers also experienced psychological distress after combat 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

Disasters and stress disorders Acute or posttraumatic stress disorders may also follow natural and accidental disasters 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

Victimization and stress disorders People who have been abused or victimized often experience lingering stress symptoms Research suggests that more than one-third of all victims of physical or sexual assault develop PTSD Terrorism and torture The experience of terrorism or the threat of terrorism often leads to posttraumatic stress symptoms, as does the experience of torture

Combat Trauma Takes the Stand
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?

Why Do People Develop Acute and Posttraumatic Stress Disorders?
Clearly, extraordinary trauma can cause a stress disorder However, the event alone may not be the entire explanation To understand the development of these disorders, researchers have looked to the survivor’s: Biological processes Personalities Childhood experiences Social support systems Cultural backgrounds Severity of the traumas

Biological and genetic factors Traumatic events trigger physical changes in the brain and body that may lead to severe stress reactions and, in some cases, to stress disorders Some research suggests abnormal neurotransmitter and hormone activity (especially norepinephrine and cortisol) Evidence suggests that once a stress disorder sets in, further biochemical arousal and damage may also occur (especially in the hippocampus and amygdala) There may be a biological/genetic predisposition to such reactions

Personality factors Some studies suggest that people with certain personalities, attitudes, and coping styles are particularly likely to develop stress disorders Risk factors include: Preexisting high anxiety Negative worldview A set of positive attitudes (called resiliency or hardiness) is protective against developing stress disorders

Childhood experiences Researchers have found that certain childhood experiences increase risk for later stress disorders Risk factors include: 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

Social support People whose social support systems are weak are more likely to develop a stress disorder after a traumatic event

Multicultural factors There is a growing suspicion among clinical researchers that the rates of PTSD may differ among ethnic groups in the US 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

Severity of the trauma Generally, the more severe the trauma and the more direct one's exposure to it, the greater the likelihood of developing a stress disorder Especially risky: Mutilation and severe injury; witnessing the injury or death of others

How Do Clinicians Treat Acute and Posttraumatic Stress Disorders?
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 General goals: End lingering stress reactions Gain perspective on painful experiences Return to constructive living

Treatment for combat veterans Drug therapy Antianxiety and antidepressant medications are most common Behavioral exposure techniques 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

Virtual Reality Therapy: Better than the Real Thing?
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?

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 Four-stage approach: Normalize responses to the disaster Encourage expressions of anxiety, anger, and frustration Teach self-help skills Provide referrals The approach has come under careful scrutiny While many health professionals continue to believe in the approach despite unsupportive research findings, the current climate is moving away from outright acceptance It's possible that certain high-risk individuals may profit from debriefing programs but that others shouldn't receive such interventions

Dissociative Disorders
The key to our identity – the sense of who we are and where we fit in our environment – is memory 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

When such changes in memory lack a clear physical cause, they are called “dissociative” disorders In such disorders, one part of the person's memory typically seems to be dissociated, or separated, from the rest Dissociative symptoms are often found in cases of acute or posttraumatic stress disorders When such symptoms occur as part of a stress disorder, they do not necessarily indicate a dissociative disorder (a pattern in which dissociative symptoms dominate)

Types of dissociative disorders include: Dissociative amnesia Dissociative fugue Dissociative identity disorder (multiple personality disorder) Depersonalization-derealization disorder

Dissociative Amnesia People with dissociative amnesia are unable to recall important information, usually of an upsetting nature, about their lives 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

Dissociative Amnesia Dissociative amnesia may be:
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 All forms of the disorder are similar in that the amnesia interferes mostly with a person’s memory Memory for abstract or encyclopedic information – usually remains intact Clinicians do not known how common dissociative amnesia is, but many cases seem to begin serious threats to health and safety

Dissociative Fugue People with dissociative fugue not only forget their personal identities and details of their past, but also flee to an entirely different location 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 When people are found before their fugue has ended, therapists may find it necessary to continually remind them of their own identity The majority of people regain most or all of their memories and never have a recurrence

Dissociative Identity Disorder (Multiple Personality Disorder)
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

At any given time, one of the subpersonalities dominates the person's functioning 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 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

How Do Subpersonalities Interact?
Generally there are three kinds of relationships: 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” The relationship between or among subpersonalities varies from case to case

How Do Subpersonalities Interact?
Investigators used to believe that most cases of the disorder involved two or three subpersonalities Studies now suggest that the average number is much higher – 15 for women, 8 for men There have been cases of more than 100

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 Abilities and preferences 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

How common is DID? 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 Some researchers even argue that many or all cases are iatrogenic; that is, unintentionally produced by practitioners These arguments are supported by the fact that many cases of DID first come to attention only after a person is already in treatment Not true of all cases

How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder?
A variety of theories have been proposed to explain dissociative disorders Older explanations have not received much investigation Newer viewpoints, which combine cognitive, behavioral, and biological principles, have captured the interest of clinical scientists

The psychodynamic view Psychodynamic theorists believe that dissociative disorders are caused by repression, the most basic ego defense mechanism 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

The psychodynamic view Most of the support for this model is drawn from case histories, which report brutal childhood experiences, yet: 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?

The behavioral view Behaviorists believe that dissociation grows from normal memory processes and is a response learned through operant conditioning: 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

State-dependent learning 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 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

State-dependent learning 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

Self-hypnosis 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 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

How Are Dissociative Amnesia and Dissociative Identity Disorder Treated?
People with dissociative amnesia and fugue often recover on their own Only sometimes do their memory problems linger and require treatment 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

How Do Therapists Help People With Dissociative Amnesia And Fugue?
The leading treatments for these disorders are psychodynamic therapy, hypnotic therapy, and drug therapy 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

How Do Therapists Help Individuals With DID?
Unlike victims of dissociative amnesia or fugue, people with DID do not typically recover without treatment Treatment for this pattern, like the disorder itself, is complex and difficult

Recognizing the disorder 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

Recovering memories To help patients recover missing memories, therapists use many of the approaches applied in other dissociative disorders, including psychodynamic therapy, hypnotherapy, and drug treatment These techniques tend to work slowly in cases of DID

Integrating the subpersonalities 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 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

Depersonalization-Derealization Disorder
DSM-5 categorizes depersonalization-derealization 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)

People with this disorder feel as though they have become separated from their body and are observing themselves from outside This sense of unreality can extend to other sensory experiences and behavior 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

The disorder occurs most frequently in adolescents and young adults, hardly ever in people older than 40 The disorder comes on suddenly and tends to be long-lasting Few theories have been offered to explain the disorder and little research has been conducted on the problem

Disorders of Trauma and Stress

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