NB11-4 - Trauma and Stressor Related Disorders and Dissociative Disorders

Question 1

List the trauma and stressor related disorders

Answer 1

• PTSD
• Acute stress disorder
• Adjustment disorder
• Reactive attachment disorder
• Disinhibited social engagement disorder

Question 2

What do all of the trauma/stressor related disorders have in common?

Answer 2

Psychological distress in response to one of two types of stressors:

• Traumatic Stressor - involves exposure to actual/threatened death, serious injury, or sexual violence (inlucing witnessing the event and sometimes even just learning about an event)
• Non-traumatic Stressor - involves situations in which a person perceives that environmental demands exceed one’s resources to cope

Question 3

What are the diagnostic criteria for posttraumatic stress disorder (PTSD)?

Answer 3

Exposure to a traumatic stressor causing one or more symptoms from each of the following categories to develop and persist for at least one month:

• Intrustion Symptoms - reliving of the event (dreams, etc)
• Avoidance Symptoms - avoiding reminders of the event
• Negative Alteration in Cognition and Mood - depression, cynicism, lost interest, estrangement, dissociative amnesia
• Alterations In Arousal and Reactivity - insomnia, irritability, recklessness, concentration problems, hypervigilance, exaggerated startle response

Question 4

What populations are most vulnerable to developing PTSD and how long after the traumatic event do symptoms present?

Answer 4

PTSD often occurs in young adults (due to military service) and patients who’ve experienced sudden-onset life-threatening medical events. Howevery, PTSD can happen to anyone.

Symptoms usually begin within 3 months of the trauma but can begin ANYTIME.

Question 5

What are the diagnostic criteria for acute stress disorder (ASD)?

Answer 5

Some critera for PTSD except these symptoms start and resolve within 3 days to 1 month after trauma exposure while PTSD symptoms can start anytime and must last longer than 30 days.

Question 6

Answer 6

A

Question 7

In PTSD/ASD patients, what underlies many of the intrusion symptoms and alterations in arousal/reactivity?

Answer 7

• Hyperresponsive amygdala
• Underresponsive PFC (failure to suppress fear)
• Reduced volume and/or dysfunction of hippocampus (failure to suppress fear when in safe contexts or form extinction memory)

Question 8

What are the PTSD/ASK treatment plans?

Answer 8

• Psychotherapy
  
  • Supportive therapy offering safe environment to express feelings
  • Behavioral therapy to address specific problematic behaviors
• Medication (secondary to psychotherapy)
  
  • Antidepressants
  • Benzodiazepines

Question 9

What are the diagnostic criteria for adjustment disorder? What are the subtypes of this disorder?

Answer 9

Acute onset of significant and disproportional emotional/behavioral symptoms in direct response to an identifiable psychosocial stressor (ie - job loss, divorce, etc). Symptoms would expectantly resolve themselves if stressor was removed. Symptoms must not be explainable by another disorder. Three subtypes:

• -with depression
• -with anxiety
• -with disturbance of conduct (ie - acting out)

Adjustment disorder is diagnosed only if there is a causal stressor AND no other disorder explains the symptoms

Question 10

Answer 10

Question 11

Answer 11

D

Question 12

What is the typical treatment plan for adjustment disorders?

Answer 12

Treatment typically involves:

• learning of coping strategies in psychotherapy sessions
• involvement in support groups
• Treatment may also require crisis intervention such as hospitalization and psychotropic medications

Question 13

List and describe the stressor/trauma related disorders that are a direct result of pathogenic care from early life.

Answer 13

Reactive Attachment Disorder (RAD) - inhibited and emotionally withdrawn behavior towards adult caregivers. Caused by an unhealthy attachment phase.

Disinhibited Social Engagement Disorder (DSED) - overly familiar behavior with relative strangers. Also caused by an unhealthy attachment phase.

Question 14

List the dissociative disorders we need to know and what they all have in common.

Answer 14

1. Dissociative Amnesia
2. Dissociative Identity Disorder
3. Depersonalization/Derealization Disorder

All of these involve some form of dissociation which is the splitting off from conscious awareness an aspect of self; usually as a coping strategy for stress.

Question 15

What are the diagnostic criteria for dissociative amnesia? Mention any specifiers that can go along with this disorder.

Answer 15

Memory loss for autobiographical information, which doesn’t occur due to another disorder. Memory loss can be:

• Localized - total loss during a circumscribed period
• Selective - partial loss during a circumscribed period
• Generalized - total loss of entire life up to and including event

Sometimes purposeful travel or bewildered wandering occurs after the amnesia. If this is the case, then the diagnosis is dissociative amnesia with dissociative fugue

Question 16

What differential diagnoses must be considered before diagnosing dissociative amnesia?

Answer 16

Organically based amnesia (there’s damage to the memory forming centers of the brain). This can be ruled out during a mental status exam (MSE) by asking the patient to recall something you told them to remember a few minutes earlier. If they can remember then anterograde memory is fine and the memory loss is likely not organically based.

Question 17

Answer 17

A

Question 18

What are the diagnostic criteria for dissociative identity disorder (DID)? What else is DID known as?

Answer 18

Dissociative identity disorder, or multiple personality disorder, is a disruption of identitiy characterized by at least two or more distinct personality states and an inability to recall personal information (as evidenced by frequent memory gaps in host while an alter ego takes control).

Question 19

What are the diagnostic criteria for depersonalization and derealization disorders?

Answer 19

Depersonalization - experiences of unreality, detachment or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions

Derealization - experiences of unreality or detachment with respect to surroundings (ie - objects seen unreal)

For both disorders reality testing remains intact (patient knows that the perceptual experience is just a misperception) and the symptoms must result in functional impairment. Also, pathological conditions should be eliminated as causal agents.

Question 20

Answer 20

C

Question 21

What are the biological causes of dissociation?

Answer 21

Largely unknown

All we know is it has something to do with a defect in the retrieval of memories.

Question 22

How are dissociative disorders treated?

Answer 22

Typically involves some from of psychotherapy

Hypnosis may be used to help recover memories but with extreme caution due to “false memory syndrome.”