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PYB306 Psychopathology > 7. Acute stress, PTSD, dissociative and somatic symptom disorders > Flashcards

7. Acute stress, PTSD, dissociative and somatic symptom disorders Flashcards

1
Q

Trauma

A

“ Trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain and body. This imprint has ongoing consequences for how the human organism manages to survive in the present.” (van der Kolk, 2015, p. 21)

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2
Q

Traumatic stress according to the DSM V

A

an event that involves actual or threatened death, serious injury, or sexual violence to self, or witnessing others experience trauma, learning that loved ones have been traumatized, or repeatedly being exposed to details of trauma.

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3
Q

symptoms for both acute and posttraumatic stress disorder

A
  • 1.Intrusive re-experiencing
  • 2.Avoidance of reminders
  • 3.Increased arousal or reactivity
  • 4.Negative mood or thoughts
  • 5.Dissociative symptoms
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4
Q

Symptoms of ASD and PTSE

A

Intrusive re-experiencing
Avoidance
Negative mood/thoughts
Arousal or ractivity

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5
Q

Intrusive re-experiencing

A
  • Intrusive, distressing images or thoughts
  • Flashbacks
  • Horrifying dreams
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6
Q

Avoidance

A

•Attempts to avoid thoughts, feelings related to the event
•Avoid people, places, or activities etc that are reminders
of the event

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7
Q

Negative mood/thoughts

A
  • Anhedonia
  • Fear, anger, guilt
  • Numbing of responsiveness
  • Self blame
  • Negative world view
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8
Q

Arousal or reactivity

A
  • Hypervigilance
  • Restlessness, agitation, & irritability
  • Exaggerated startle response
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9
Q

The main symptom of trauma or PTSD and ASD

A

Dissociation

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10
Q

Dissociation

A

• Argued to be the essence of trauma
• Overwhelming experience is split off and fragmented
• This includes all the various ways the survivor attempts to forget about the event (often these are not conscious). Lanius et al (2005): ‘A nonverbal
response to a traumatic memory.’
• Can include numbing, freezing, emotional constriction, cut off from
environment, also from body.
• Occurs on a continuum from mild (e.g. daydreaming, transitions
between sleep and waking) to extreme dissociative experiences where
the person becomes disconnected from reality

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11
Q

Hormones during trauma

A

“As long as the trauma is not resolved, the stress hormones that the body secretes to protect itself keep circulating, and the defensive movements and emotional responses keep getting replayed.” (van der Kolk, 2014)

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12
Q

Diagnosis of ASD - criterion A

A

A. Exposure to “trauma” (as defined by DSM-5)
1. Directly experiencing traumatic event
2.Witnessing event (in person) occurring to another
3.Learning the traumatic event occurred to a close relation
4. Experiencing repeated or extreme exposure to aversive details of
traumatic events (e.g. therapist exposed to details of child abuse)

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13
Q

Diagnosis of ASD - criterion B

A 
B. Presence of 9 or more sx from any of the 5 categories
•Intrusion
• Negative mood
• Dissociative symptoms
• Avoidance Symptoms
• Arousal Symptoms
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14
Q

Intrusion symptoms of ASD in DSM 5

A
  1. Recurrent, intrusive distressing memories
  2. Recurrent distressing dreams
  3. Dissociative reactions (e.g. flashbacks)
  4. Intense or prolonged psychological distress or marked physiological reactions
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15
Q

Negative mood symptoms of ASD in DSM 5

A
  1. Persistent inability to experience positive emotions
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16
Q

Dissociative symptoms of ASD in DSM 5

A
  1. Altered sense of reality

7. Inability to remember important parts of traumatic event

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17
Q

Avoidance symptoms of ASD in DSM 5

A
  1. Efforts to avoid distressing memories, thoughts, feelings

9. Efforts to avoid external reminders

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18
Q

Arousal symptoms of ASD in DSM 5

A
  1. Sleep disturbance
  2. Irritable behaviour and angry outbursts
  3. Hypervigilance
  4. Concentration problems
  5. Exaggerated startle respons
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19
Q

Required duration of trauma exposure for ASD

A

• Duration is 3days to 1month after trauma exposure

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20
Q

Other criteria of ASD

A

• Causes clinically significant distress
• Not attributable to effects of substances or another medical condition
*Conceptually precedes PTSD
*Unnecessarily “confusing” (6 vs 9 symptoms)
*Normal vs abnormal reactions to abnormal event

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21
Q

PTSD diagnosis criteria

A

A. Exposure to “trauma” (as defined by DSM-5)
B. Intrusion symptoms beginning after event (1 or more/5)
C. Persistent avoidance of stimuli associated with traumatic
event (1 or both/2)
D. Negative alterations in cognitions and mood (2 or more/7)
E. Marked alterations in arousal and reactivity (2 or more/6)
F. Duration of disturbance is more than 1 month (Criteria B, C, D, E)
G. Disturbance causes clinically significant distress or impairment
H. Disturbance not attributable to the physiological effects of a
substance or another medical condition

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22
Q

Exposure to trauma requirement for PTSD

A
  1. Directly experiencing traumatic event
  2. Witnessing event (in person) occurring to another
  3. Learning the traumatic event occurred to a close relation
  4. Experiencing repeated or extreme exposure to aversive details of
    Traumatic events (e.g. therapist exposed to details of child abuse)
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23
Q

Intrusion symptoms of PTSD

A
  1. Intrusive, recurrent memories
  2. Recurrent, distressing dreams
  3. Dissociative reactions (e.g. flashbacks)
  4. Intense or prolonged psychological distress at exposure to internal/external cues
  5. Marked physiological reactions to internal/external cues
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24
Q

Persistent avoidance of stimuli associated with traumatic event symptom of PTSD

A
  1. avoidance/attempts to avoid distressing memories, thoughts, feelings
  2. Avoidance or efforts to avoid external reminders (e.g. people/places)
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25
Q

Negative alterations in cognitions and mood (2 or more/7) symptoms of PTSD

A
  1. Inability to remember aspects of traumatic experience
  2. Persistent negative beliefs about self, others, world
  3. Persistent, distorted cognitions about event (blame self/others)
  4. Persistent negative emotional state (e.g. anger, shame)
  5. Markedly diminished interest in sig. activities
  6. Feelings of detachment or estrangement from others
  7. Persistent inability to experience positive emotions
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26
Q

Marked alterations in arousal and reactivity (2 or more/6) symptom

A
  1. irritable behaviour and angry outbursts
  2. reckless or self-destructive behaviour
  3. hypervigilance
  4. exaggerated startle response
  5. problems concentrating
  6. sleep disturbance
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27
Q

Frequency of trauma, PTSD and ASD

A

• estimates for PTSD worldwide vary around 6-8% (lifetime risk is ~9% in USA, DSM-5
)
• More common women (10% of females) than men (5% of males; why?)
• Minorities are more likely experience PTSD (why?)

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28
Q

Comorbidity of trauma, PTSD and ASD

A
  • High for depression, other anxiety disorders, and substance abuse *What does this mean for our diagnostic system?
  • Anger – usually very prominent; Risk for suicide
  • ASD ➔ PTSD
  • Numbing, depersonalisation, re-living
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29
Q

Risk factors of ASD and PTSD

A

• Nature of the trauma (intensity, frequency, type of
trauma, age of trauma)
• Lack of social support
• Other stressful events afterwards (e.g., refugee
experience of incarceration & uncertainty)
• Personality vulnerability (anxiety)
• Genetic contributions – not a lot of research around
this (but also environment) – possibly epigenetics

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30
Q

Complex trauma

A

Complex trauma occurs when the trauma is on-going, often in the context of a relationship which must be endured and managed – eg, child abuse, domestic violence

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31
Q

Single event trauma versus complex trauma (or developmental trauma)

A
  • Bessel van der Kolk (2012) has said that a single event is more likely to lead to the condition Post-Traumatic Stress Disorder (PTSD), and to the intrusive reliving of the event (sometimes called a ‘flashback’, drawn from terminology associated with psychotropic drug experiences, eg, LSD).
  • van der Kolk and others propose that when a person experiences a traumatic relationship, such as occur in child abuse, a more complex form of trauma develops which is often called complex trauma or sometimes developmental trauma.
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32
Q

Types of abuse

A

physical
sexual
emotional
neglect

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33
Q

physical abuse

A

– hitting, punching, kicking, shaking, beating, burning

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34
Q

sexual abuse

A

penetration, exploitation, exposure to pornographic material

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35
Q

Emotional abuse

A

scapegoating, rejection, persistent hostility, ignoring, isolating, terrorising, verbal abuse, blaming, threatening, discriminating against, ridiculing and belittlement

36
Q

neglect abuse

A

failure to attend to needs, inadequate supervision, withholding of affection or attention, failure to provide a child with the appropriate support/security

37
Q

The impact of developmental trauma on children

A

different to other types of trauma (experienced by adults), as the trauma occurs in key critical stages of development and therefore impacts:
• Assumptions about self, others, and the world
• Relationship to own internal states
• Capacity to regulate emotions and cope adaptively with life
• The development of the brain
• Template for relationships

38
Q

Difficulties experienced by children who experience developmental trauma

A 
Academic entration
Physiological
conduct
Emotional and behavioural
social
39
Q

The effect of developmental trauma, maltreatment and attachment

A
  • A bond that forms between the infant and primary caregiver – provides the working framework for all other relationships
  • A key conflict for children who have experienced abuse is between the child’s attachment to the caregiver, on the one hand, and the experiences of that caregiver as abusive and uncaring, on the other
  • This often creates an internal working model of relationships that are impossible to integrate
  • Significant body of research has found maltreated children have insecure or disorganised attachment styles (for example see Perry, van der Kolk)
40
Q

Emotional dysregulation

A
  • Dysregulation occurs when the child becomes overwhelmed by the emotion.
  • All types of child abuse impacts on children’s ability to regulate their emotions (Friedrich)
41
Q

hyperarousal

A

Body goes into a state of alert

42
Q

symptoms of hyperarousal

A
  • Symptoms include sleeping problems, irritability, anxiety, difficulty concentrating
  • Fight, flight, or freeze - Purpose is instant response, which is probably why other neural processes are often disrupted.
43
Q

neurological results of hyperarousal

A

Continuous or chronic stress overwhelms the warning function of the amygdala, which normally appraises sensory information for risk.

44
Q

expression of hyperarousal

A

often expressed later in life as chronic irritability; also over-reacting emotionally

45
Q

Long-term effects of hyperarousal

A

Can lead to a variety of somatic problems later in life, including heart and blood pressure problems

46
Q

Dissociation

A

“Dissociation refers to a compartmentalization of experience: elements of the experience are not integrated into a unitary whole, but are stored in memory as isolated fragments and stored as sensory perceptions, affective states or as behavioral reenactments.”

(van der Kolk & Fisler, 1995)

47
Q

How do effects of childhood trauma can

persist over time?

A

• The early developmental impacts of trauma can, and
normally do last a life-time.
• The literature to support this claim, based on the
neurological impacts of violence and neglect, is
currently massive.
• Adverse Childhood Experiences (ACEs) study – results
were devastating:
• Over 17000 participants
• Looked at exposure to ACE and outcomes in adults
• Children didn’t “outgrow” the impacts – pervaded their lives
• More adverse experiences in childhood linked to higher rates
of mental illness, drug/alcohol use, suicide attempts, financial
problems, health problems (smoking, obesity, unintended
pregnancy, cancer, emphysema)

48
Q

Long term impacts of childhood trauma

A
  • Can create a disorder which persists
  • Can create bodily changes which persist
  • Can alter a pattern of behaviour, which persists
  • Can change family relations and circumstances, which persist
  • Sensitivities to stress or coping strategies created, which persist, increasing or decreasing future vulnerability
  • Changes in child’s self-concept or attitudes persist
  • Can influence selection of environments later which open or close opportunities
49
Q

Number of diagnoses in children who have experienced trauma

A
  • In children who have experienced developmental trauma – have on average 4-6 diagnoses
  • Common diagnoses include ADHD, autism, conduct disorder
50
Q

Why is misdiagnosis common?

A

• In adults, Ross (2000, 2006 (s), 2011 (s)) estimated that
approximately 75% of mental health patients of
descriptions had some form of interpersonal abuse in
their developmental histories.
• He said of his own patients at his Dallas clinic that each
has attracted about 13 separate diagnoses on average.
The chance of a person having 13 discrete mental
illnesses he calculated to be approximately one in a
trillion.
• Large scale studies of in-patients have found as high as
95% have been either physically or sexually abused.
• In adults – common diagnoses include personality disorders (particularly Borderline PD), Bi-polar, substance abuse

51
Q

Three ways that treatment can occur for trauma

A
  1. Top-down approaches through talking/connecting with other people (certain therapies)
  2. Taking medications that shut down inappropriate threat responses
  3. Bottom up approaches – providing the body with experiences that viscerally contradict or collapse the responses that result from trauma
52
Q

Psychotherapy approaches to trauma

A
  • Relationship is key
  • Interpersonal psychotherapy
  • Interventions focusing on the brain
  • Somatosensory interventions
  • EMDR
  • Exposure therapy
53
Q

Relationship as a key aspect of trauma treatment

A

• Relationship is key – particularly in complex trauma as the trauma happens in the context of relationships so healing needs to occur in the context of relationships

54
Q

Interpersonal psychotherapy as a treatment for trauma

A

relationships, affect regulation, self-concept, personal control, & personal meaning of trauma

55
Q

Interventions focusing on the brain as a treatment for trauma

A

e.g. Neurosequential Model of Therapeutics

56
Q

Somatosensory interventions as a treatment for trauma

A

– e.g. sensorimotor therapy

57
Q

exposure therapy as a treatment for trauma

A

– confronting memories & feared situations – have to be very careful with this, timing is key and may not be appropriate to use

58
Q

What is critical when treating trauma?

A

Timing and care

59
Q

what is the effect of unresolved trauma on integration abilities?

A

• Janet (1889) – profound deficits in the ability to integrate experiences occurs in people with unresolved trauma, so may take other forms (e.g. dissociative/somatic)

60
Q

Failure in integration leads to…

A

“compartmentalization of experience: elements of a trauma are not integrated into a unitary whole or an integrated sense of self” (van der Kolk et al., 1996)

61
Q

Comorbidity and treatment of dissociative and somatic disorders

A

lots of people have both dissociative and somatoform disorders. both are understood and treated in similar ways

62
Q

dissociation

A

Traumatic stress disorders, dissociative disorders, and SSDs look different, but share an important similarity: dissociation – the disruption of the normally integrated mental processes.

63
Q

Depersonalization/derealization

A

feeling of being detached from the world around us or oneself.

*”As if” feelings – not delusional beliefs e.g. I feel as if my body was not connected to my brain

64
Q

core features of dissociative disorders

A

persistent, maladaptive disruption in the integration of memory, consciousness, identity, emotion, perception, body representation, motor control and behaviour.

65
Q

Specific diagnoses of dissociative disorders

A
  • Dissociative Amnesia
  • Depersonalization Disorder
  • Dissociative Identity Disorder
66
Q

Dissociative identity disorder

A

A. Disruption of identity characterized by two or more distinct
personality states, which may be described in some cultures as an
experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency,
accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensorymotor functioning. These signs and symptoms may be observed by others or reported by the individual
B. Gaps in the recall of important personal information that are
inconsistent with ordinary forgetting
C. Distress or impairment
D. Not explained by cultural factors or religion
E. Exclude substance, medical condition

67
Q

primary and alternate identites in DID

A
  • The “primary” identity may be relatively passive, dependent, or report feeling guilty or depressed
  • Alternates usually contrast to primary
  • Differ in age, gender, skills, mannerisms
  • Alternates can emerge in response to specific situations/emotions
  • 10 or fewer alternates most common
68
Q

Associated features of dissociative identity disorder

A
  • Confusion and memory gaps
  • Self harm or suicidal behaviour
  • Common comorbid diagnoses: Mood, substance, sexual, eating, sleep.
  • More common in women (why?)
69
Q

When can dissociative identity disorder present?

A

the full disorder can first present at any age

70
Q

DID controversies

A
  1. Most cases of dissociative disorders are diagnosed by a handful of “ardent” clinicians;
  2. they rarely occur outside of USA & Canada
  3. The frequency of dissociative disorders (& DID in particular increased) rapidly after release of the very popular book & movie Sybil. (cf. Sar, 2011 - under-diagnosed)
  4. The number of personalities claimed to exist has grown rapidly [what could explain this]?
  5. Symptoms of DDs are more extreme than those found in measures of dissociation
71
Q

Etiology of DID

A

Generally accepted that childhood trauma plays a key role in development of DID
*90% of people with DID in United States, Canada, and Europe reported history of child abuse/neglect
[but the data are often only retrospective, ?verifiable, and as with PTSD, most people who experience trauma do not develop a DD, including DID].
• The possibility of a “social” cause or contribution? - Iatrogenesis

72
Q

Treatment and management of DID

A

poorly evaluated at this time
Possibly: integration via uncovering the trauma about which the person might not even be aware? or aiming for acceptance of & “co-operation” among the alters (ISSTD, 2011).

73
Q

Essential features of somatic symptom disorders

A

(for SSDs, except Factitious)
–Complaints about physical symptoms in the absence of a medical cause that are psychologically distressing / impairing
–The complaint is experienced as “bodily” and real [like an ordinary (medically explained) symptom].
–Often associated with numerous, evolving, and nonspecific
complaints such as chronic pain, upset stomach, dizziness.

74
Q

Categories of Somatic symptom disorder

A
  • Somatic symptom disorder
  • Conversion disorder
  • Illness anxiety disorder (Hypochondriasis)
  • Psychological factors affecting other medical conditions
  • Factitious Disorder
75
Q

Conversion Disorder

A

“People with this disorder display physical symptoms that affect voluntary motor or sensory functioning, but
the symptoms are inconsistent with known medical diseases…..In short, the individuals experience neurological like symptoms – blindness, paralysis, or loss of feeling - that have no neurological basis”

Serious neurological
symptoms occur and affect behaviour – here blindness in an individual with normal sight.

CD is rare and thought to
occur at times of acute
stress.

76
Q

Conversion Disorder criteria

A

A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. Not due to another medical or mental disorder.
D. Distressing/Impairment

77
Q

Symptoms of conversion disorder

A 
“Psuedo” or “functional” neurological features
–Impaired coordination
–Paralysis
-Seizures
-Tics
–Localised weakness
–Difficulty swallowing
–Loss of sense of touch / Speech
–Numbness
–Double vision/blindness
–Deafness
78
Q

Prevalence of SSD

A

Actual prevalence unknown, but typically considered

•More common among women (10 times) and in people w lower SES

79
Q

age of onset for SSD

A

Adolescence or early adultood

80
Q

Comorbidities of SSD

A

Depression, anxiety, antisocial personality disorder

81
Q

Theorised causes of SSD

A

Etiology is under-researched. SSDs are diagnosed by exclusion, which does not assist in establishing etiology; associated with stressors (also a historical link to WW1).

82
Q

Possible biological causes of SSD

A

A missed organic explanation for the Sx

83
Q

Possible physiological causes of SSD

A

– Underlying trauma / identity issues
– Difficulty with emotional /psychological expression
– Primary and secondary gain
– Cognitive tendencies: amplification, alexithymia

84
Q

Psychological treatments of SSD

A

– Interpersonal psychotherapy
– If symptoms incl. pain, operant (behavioural) approaches
might be tried
– Changing the cognitive overlay/interpretation/meaning of
symptoms

85
Q

interpersonal psychotherapy as treatment for SSD

A

addressing underlying trauma/psychological conflict/identity reintegration – historically, “cathartic” therapies for CD –promoting emotional expression/recognition

86
Q

operant (behavioural) treatments for SSD

A

rewarding successful coping and adaptation

87
Q

Changing the cognitive overlay/interpretation/meaning of symptoms as treatment for SSD

A

cognitive behavioural therapy; cognitive restructuring

PYB306 Psychopathology (13 decks)

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