Ch. 5 Disorders of Trauma and Stress

Question 1

Stress and Arousal: Fight or Flight

Answer 1

STRESS – We feel some degree of stress whenever we are faced with demands or opportunities that require us to change in some manner. The state of stress has two components:

• STRESSOR – the event that creates the demands
• STRESS RESPONSE – the person’s reactions to the demands

HYPOTHALAMUS – When our brain interprets a situation as dangerous, neurotransmitters in the hypothalamus are released, activating two systems:

• AUTONOMIC NERVOUS SYSTEM (ANS) – the network of nerve fibers that connect the central nervous system (the brain and spinal cord) to all the other organs of the body. These fibers help control the involuntary activities of the organs— breathing, heartbeat, blood pressure, perspiration.
  
  • SYMPATHETIC NERVOUS SYSTEM PATHWAY – When we face a dangerous situation, the hypothalamus first excites the sympathetic nervous system, a group of ANS fibers that work to quicken our heartbeat and produce the other changes that we come to experience as fear or anxiety.
    
    • When the ADRENAL MEDULLA is stimulated, the chemicals EPINEPHRINE (adrenaline) and NOREPINEPHRINE (noradrenaline) are released.
  • PARASYMPATHETIC NERVOUS SYSTEM – When the perceived danger passes, a second group of ANS fibers, called the parasympathetic nervous system, helps return our heartbeat and other body processes to normal.
  • Together the sympathetic and parasympathetic nervous systems help control our arousal reactions.
• ENDOCRINE SYSTEM – the network of glands located throughout the body that release HORMONES into the bloodstream and on to the various body organs.
  
  • HYPOTHALAMIC-PITUITARY-ADRENAL (HPA) PATHWAY – The second brain–body pathway by which arousal is produced.
    
    • When we are faced with stressors, the hypothalamus also signals the PITUITARY GLAND, which lies nearby, to secrete the ADRENOCORTICOTROPIC hormone (ACTH), sometimes called the body’s “major stress hormone.” ACTH, in turn, stimulates the outer layer of the adrenal glands, an area called the ADRENAL CORTEX, triggering the release of a group of stress hormones called CORTICOSTEROIDS, including the hormone CORTISOL. These corticosteroids travel to various body organs, where they further produce arousal reactions.
• The Sympathetic Nervous System Pathway and the HPA Pathway are the two pathways that arouse the body and prepare us for a response to danger. Thus, the reactions on display in these two pathways are collectively referred to as the FIGHT OR FLIGHT RESPONSE.

Question 2

Acute and Posttraumatic Stress Disorders

Answer 2

ACUTE and POSTTRAUMATIC STRESS DISORDERS – symptoms of arousal, anxiety, and depression, as well as other kinds of symptoms, persist well after the upsetting situation is over.

• Usually in reaction to a traumatic event in which a person is exposed to actual or threatened death, serious injury, or sexual violation.
• 3.5-6% of people have this in a given year, 7-12% during their lifetime.
• In almost all disorders (except OCD) women are TWICE as likely to suffer from the disorder, and also the poor more than the rich.

ACUTE STRESS DISORDER – a person experiences fear and related symptoms soon after a trauma but for less than a month.

• 50% of all cases of ACUTE STRESS DISORDER develop into PTSD.

POSTTRAUMATIC STRESS DISORDER – a person experiences fear and related symptoms long after a traumatic event.

• 25% of people with PTSD do not develop a full clinical syndrome until 6 months or more after their trauma.
• Aside from the differences in onset and duration, the symptoms of acute stress disorder and PTSD are almost identical:
  
  • Increased arousal, negative emotions, guilt, reexperiencing the trauma, avoidance, reduced responsiveness, and DISSOCIATION (psychological separation) – two types:
    
    • DEPERSONALIZATION – feeling that their conscious state or body is unreal.
    • DEREALIZATION – feeling that the environment is unreal or strange.

CAUSES of ASD and PTSD:

• Combat – known as “Shell Shock” in WWI and “Combat Fatigue” in WWII. (29% of those in Vietnam war and 20% of those in Iraq/Afghanistan)
• Disasters and Accidents – between 12-40% of those involved in a traffic accident may develop PTSD within a year of the accident.
• Victimization – 1/3 of all victims of physical or sexual assault develop PTSD
  
  • Around 1/6 of all women are RAPED during their lifetime.
    
    • Effects of RAPE can continue 18 months or longer and victims suffer from RAPE TRAUMA SYNDROME (RTS), a pattern of problematic physical and psychological symptoms. RTS is actually a form of PTSD.
    • Approximately one-third of rape victims develop PTSD.
• Terrorism and Torture as well.

WHY DO ONLY SOME OF THOSE WHO EXPERIENCE TRAUMA DEVELOP PTSD?

BIOLOGICAL – There are biological factors that create a predisposition for PTSD.

• BRAIN-BODY STRESS PATHWAYS – the sympathetic nervous system pathway (through nerve cell firing) and the hypothalamic-pituitary-adrenal (HPA) pathway (through releasing hormones) react to stress by producing a general state of arousal.
  
  • People who develop PTSD react with especially heightened arousal in the pathways. Even prior to confronting a severe trauma, such individuals’ pathways are overly reactive to modest stressors, thus setting up a predisposition to develop PTSD.
• BRAIN’s “STRESS CIRCUIT” – chronic over-reactivity of the two stress pathways may help bring about dysfunction in a distinct brain circuit.
  
  • As you might guess, the STRESS CIRCUIT overlaps the brain’s FEAR CIRCUIT and PANIC CIRCUIT.
• INHERITED PREDISPOSITION – some people inherit a tendency for overly reactive brain–body stress pathways and a dysfunctional brain STRESS CIRCUIT, predisposing them to PTSD.
  
  • Stress can be transferred genetically as shown in studies of women with heightened cortisol levels (stress hormone) who give birth to babies who also had elevated cortisol levels.
• CHILDHOOD EXPERIENCES – a predisposition to PTSD may be may also be acquired during childhood rather than inherited at birth.
  
  • Studies have found that young children who are chronically neglected or abused or otherwise traumatized develop overly reactive stress pathways and a dysfunctional brain STRESS CIRCUIT that carry into later life.
  • PERSONAL STYLES – people with certain personalities, attitudes, and coping styles are particularly likely to develop PTSD.
    
    • People who generally view life’s negative events as beyond their control tend to be at risk for PTSD.
    • RESILIENCY – the ability or mindset to adapt well and cope effectively in the face of life adversity – a skill strengthened by exposure to manageable stress during childhood. Those who are resilient are less likely to develop PTSD in the face of trauma.
• SOCIAL SUPPORT SYSTEMS – People whose social and family support systems are weak are also more likely to develop PTSD after a traumatic event.
• SEVERITY AND NATURE OF THE TRAUMA – The more severe the trauma, the more likely people are to develop PTSD (duh!)
  
  • People who experience INTENTIONALLY inflicted traumas are more likely to develop a stress disorder than persons who encounter UNINTENTIONAL traumas.
  • COMPLEX PTSD – encounters with multiple or recurring traumas can lead to a particularly severe pattern with profound disturbances in their emotional control, self-concept, and relationships.

DEVELOPMENTAL PSYCHOPATHOLOGY – the most influential explanation for how PTSD comes about.

• BIOLOGY – predisposes the individual the brain pathways
• SOCIOCULTURAL – children can be predisposed by their environment through traumas including a destructive parent-child relationship.
  
  • Weak social supports also contribute to the susceptibility of developing a stress disorder.
• Notes that the timing of stressors and traumas over the course of development has a profound influence on whether an individual will develop PTSD.
• Also notes that there are both RISK FACTORS and PROTECTIVE FACTORS at work in determining the likelihood of developing a stress disorder meaning the path and the destination vary from person to person.
  
  • MULTIFINITY – the notion that persons with similar beginnings may wind up at very different endpoints.
  • EQUIFINALITY – the notion that different developmental pathways may lead to the same endpoint.

TREATMENT – 1/3 of all cases of posttraumatic stress disorder improve within 12 months.

• 1/3 of all cases of posttraumatic stress NEVER fully recover.
• Treatment for COMBAT VETS include:
  
  • Antidepressants
  • Cognitive Behavioral Therapy:
    
    • Mindfulness techniques
    • Exposure Training – the single most effective treatment is PROLONGED EXPOSURE – where therapists direct clients to confront not only trauma-related objects and situations but also their painful memories of traumatic experiences—memories they have been actively avoiding. The clients repeatedly recall and describe the memories in great detail for extended periods of time, holding on to them until becoming less aroused, anxious, and upset by them.
    • EYE-MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR) – An exposure treatment in which clients move their eyes in a rhythmic manner from side to side while flooding their minds with images of objects and situations they ordinarily avoid. (The BILATERAL EYE MOVEMENTS are effective at reducing distress, and thereby allow other components of treatment to take place.).
  • Virtual Reality Therapy – extremely helpful.
  • Couple, Family, and Group Therapy
• PSYCHOLOGICAL DEBRIEFING – A form of crisis intervention in which victims are helped to talk about their feelings and reactions to traumatic incidents. (Also called critical incident stress debriefing).

Question 3

Dissociative Disorders

Answer 3

DISSOCIATIVE DISORDERS – a group of disorders triggered by traumatic events where dissociative reactions are the main or only symptoms and no clear physical factors (Ex: head trauma, drugs) are at work.

• In dissociative disorders, one part of a person’s memory or identity becomes dissociated, or separated, from other parts of his or her memory or identity.

DISSOCIATIVE AMNESIA – are unable to recall important personal events and information. These forms of dissociative amnesia are similar in that the amnesia interferes mostly with a person’s memory of personal material. Memory for abstract or encyclopedic information usually remains.

• LOCALIZED AMNESIA – a person loses all memory of events that took place within a limited period of time, almost always beginning with some very disturbing occurrence.
  
  • This is the most common type of Dissociative Amnesia.
  • AMNESTIC EPISODE – The forgotten period. During an amnestic episode, people may appear confused; in some cases, they wander about aimlessly. Seem unaware of memory difficulties.
• SELECTIVE AMNESIA – remember some, but not all, events that took place during a period of time.
• GENERALIZED AMNESIA – memory loss extends back to times long before the upsetting period, forgetting past life events, or periods. In extreme cases, she might not even recognize relatives and friends.
• CONTINUOUS AMNESIA – forgetting continues into the present. A person might forget new and ongoing experiences as well as what happened before and during the traumatic event.
• DISSOCIATIVE FUGUE – A form of dissociative amnesia in which a person travels to a new location and may assume a new identity, simultaneously forgetting his or her past.
  
  • These tend to be brief and totally reversible, creating few aftereffects.

DISSOCIATIVE IDENTITY DISORDER – (aka. multiple personality disorder) develops two or more distinct personalities, often called SUBPERSONALITIES, each with a unique set of memories, behaviors, thoughts, and emotions.

• At any given time, one of the subpersonalities takes center stage and dominates the person’s functioning. Usually, the PRIMARY PERSONALITY appears more often than the others.
• SWITCHING – The transition from one subpersonality to another, often the result of a stressful event.
• Symptoms began in early childhood after episodes of trauma or abuse.
• Women receive this diagnosis at least three times as often as men.
• PERSONALITIES INTERACT through three primary types of relationships:
  
  1. MUTUALLY AMNESIC RELATIONSHIPS – the subpersonalities have no awareness of one another.
  2. MUTUALLY COGNIZANT PATTERNS – each subpersonality is well aware of the rest. They may hear one another’s voices and even talk among themselves. Some are on good terms, while others do not get along at all.
  3. AMNESIC RELATIONSHIPS – (the most common relationship pattern), some subpersonalities are aware of others, but the awareness is not mutual.
     
     • Those who are aware, called COCONSCIOUS SUBPERSONALITIES, are “quiet observers” who watch the actions and thoughts of the other subpersonalities but do not interact with them. Sometimes while another subpersonality is present, the coconscious personality makes itself known through indirect means, such as auditory hallucinations (perhaps a voice giving commands) or “automatic writing” (the current personality may find itself writing down words over which it has no control).
• The average number of subpersonalities per patient is much higher – 15 for women and 8 for men with as many as 100+ subpersonalities observed.
• Subpersonalities may differ in any way imaginable – age, gender, race, skills, family history, preferences, and even handwriting and physiological responses such as brain-activity patterns and blood pressure (!!).
• Encyclopedic Information can be different (unlike Amnesic disorders).
• Affects 1% of the population.
• PSYCHODYNAMIC VIEW – believe that these 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.
  
  • believe that this continuous use of repression is motivated by traumatic childhood events, particularly abusive parenting. Whenever they experience “bad” thoughts or impulses, they unconsciously try to disown and deny them by assigning them to other personalities.
  • There is some research support, but there are also many cases that do not fit this description.
• COGNITIVE-BEHAVIORAL VIEW – If people learn something when they are in a particular situation or state of mind, they are likely to remember it best when they are again in that same situation or state of mind – a link called STATE-DEPENDENT LEARNING.
  
  • Thus, when a situation produces a particular level of arousal, the person is more likely to recall the memories linked to it.
  • People who are prone to develop dissociative disorders have state-to-memory links that are unusually rigid and narrow.
    
    • Each of their thoughts may be tied to a particular state of arousal, so they recall a given event only when they experience a similar state of arousal as that when the memory was first acquired.
    • Ex: When such people are calm, they may forget what happened during stressful times, thus laying the groundwork for DISSOCIATIVE AMNESIA.
    • Similarly, in DISSOCIATIVE IDENTITY DISORDERS, different arousal levels may produce entirely different groups of memories, i.e. different subpersonalities – possibly explaining why personality transitions in dissociative identity disorder tend to be sudden and stress-related.
  • SELF-HYPNOSIS – Some theorists think that some dissociative disorders are a form of self-hypnosis where the victim has created a state of HYPNOTIC AMNESIA in order to forget the traumatic events.
    
    • The self-hypnosis theory might also be used to explain dissociative identity disorder. This disorder often begins between the ages of 4 and 6, a time when children are generally very suggestible and excellent hypnotic subjects. Children who experience abuse or other horrifying events manage to escape their threatening world by self-hypnosis, mentally separating themselves from their bodies and fulfilling their wish to become someone else.
  • TREATMENT – people with DISSOCIATIVE AMNESIA often recover on their own but can also be treated with Psychodynamic, Hypnotic, and drug therapy). Only sometimes do their memory problems linger and require treatment.
  • In contrast, people with DISSOCIATIVE IDENTITY DISORDER usually require treatment to regain their lost memories. This is usually done in three parts:
    
    1. recognize fully the nature of their disorder
    2. recover the gaps in their memory
    3. integrate their subpersonalities into one functional personality – called FUSION.

DEPERSONALIZATION-DEREALIZATION DISORDER – feel as though they have become detached from their own mental processes or bodies or are observing themselves from the outside.

• it is not characterized by the memory difficulties found in the other dissociative disorders. Its central symptoms are persistent and recurrent episodes of:
  
  • DEPERSONALIZATION – the sense that one’s own mental functioning or body is unreal or detached.
    
    • Occasionally their mind seems to be floating a few feet above them—a sensation known as DOUBLING.
  • DEREALIZATION – the sense that one’s surroundings are unreal or detached.
    
    • Transient feelings of Depersonalization or Derealization are quite common in scenarios like meditation, experiencing a new place, or in proximity to life-threatening danger. It is the persistence of these symptoms that is the disorder.
  • Throughout the whole experience, however, they are aware that their perceptions are distorted, and in that sense, they remain in contact with reality.