Trauma/stressor-related And Dissociated Disorders Flashcards
What are the trauma and stress disorders?
- Posttraumatic Stress Disorder
- Acute Stress Disorder
- Adjustment Disorder
- Reactive Attachment Disorder
- Disinhibited Social Engagement Disorder
What are the types of stressors?
Psychological distress in response to a stressful event – “overwhelmed” coping mechanisms
• Traumatic stressor: Involves actual/threatened death or serious injury
• Non-traumatic stressor: Perception that environmental demands exceed one’s resources to cope
Psychological distress can manifest in many forms (e.g., anxiety, dysphoria, anger, dissociation)
What is the PTSD diagnosis?
Exposure to a traumatic stressor:
- Actual or threatened death or serious injury or sexual violence
- Exposure may include direct experience of event, witnessing event, or learning about event that happened to a close family member/friend
As a result, 1+ symptom from each of the 4 categories of symptoms must develop:
What are the characteristics of PTSD symptoms?
1) Intrusive Symptoms • Dreams • Automatic Recollections • Feeling like the event is re-occurring • Psychological or physiological distress when encountering symbols that remind of the event
2) Avoidance Symptoms
• The individual avoids thoughts, places, or conversations that remind him/her of the event
3) Negative Alterations in Cognition and Mood
• Negative beliefs/expectations
• Negative emotional states
• Inability to experience positive emotion
• Diminished interest/participation in activities
• Detachment/estrangement from others
• Inability to remember an important aspect of the traumatic event
4) Alterations in Arousal and Reactivity
• Sleep disturbance
• Irritable and angry outbursts
• Reckless or self-destructive behavior • Concentration problems
• Hypervigilance
• Exaggerated startle response
• DSM Diagnostic Note: Specify if with dissociative symptoms
(i.e., depersonalization and/or derealization)
Describe the onset of PTSD
Duration: Symptoms must last >1 month
- Onset: Symptoms usually begin within 3 months of the trauma but can begin any time
- Vulnerable Populations: Often occurs in young adults but can happen to anyone; Patients with sudden-onset, life- threatening medical emergencies can experience PTSD
Describe the onset of ASD
Exposure to a traumatic stressor
• Numerous PTSD-like symptoms must develop from the four PTSD symptom categories or an additional category: Dissociative Symptoms
• Altered sense of the reality of one’s surroundings or oneself
• Inability to remember an important aspect of the traumatic event(s)
typically due to dissociative amnesia
• Duration of the disorder is 3 days to 1 month after trauma exposure
What is adjustment disorder?
Significant and disproportional emotional/behavioral symptoms in direct response to a stressor
• Stressor can be “ordinary” psychosocial (i.e., divorce) or traumatic
• Acute onset (symptoms develop within a few months of stressor onset)
• Brief duration (symptoms expected to resolve within a few months after stressor termination)
Symptoms aren’t explained by another disorder
Contrast ASD and PTSD
Key to differentiating ASD from PTSD is the time frame:
- ASD: Symptoms start and resolve within the first 30 days after the trauma and last 3+ days
- PTSD: Symptoms start anytime after the trauma and last more than 30 days
What are the subtypes of adjustment disorder?
Adjustment Subtypes
• with depressed mood
• with anxiety
• with disturbance of conduct (i.e., externalizing misbehavior such as vandalism)
• with mixed anxiety and depressed mood
• with mixed disturbances of emotion & conduct
• unspecified
What is the key differentiating adjustment disorder?
Key to differentiating Adjustment Disorder is process of elimination
- If sufficient symptoms (following a stressor) to match other diagnostic criteria – that is the diagnosis (e.g., Major Depressive Disorder)
- Adjustment Disorder diagnosed ONLY if there is a causal stressor AND no other disorder explains the symptoms
What can lead to RAD ?
In relation to adult caregivers: 1. 2. 3. 4. Consistent pattern of inhibited, emotionally withdrawn behavior
• Child rarely (i) seeks comfort; (ii) responds to comfort when distressed
At least 2 persistent social and emotional disturbances:
Minimal social and emotional responsiveness to others
Limited positive affect
Unexplained irritability, sadness, or fearfulness during nonthreatening interactions
At least 1 extreme of insufficient childcare:
Persistent lack of emotional needs for comfort, stimulation, and affection Repeated changes of primary caregivers
Rearing in unusual settings that limits attachment
Insufficient childcare precedes withdrawn behavior
What is Disinhibited Social Engagement Didorder?
Same as RAD diagnosis except #1 and #2: Externalizing versus internalizing behaviors
Child approaches and interacts with unfamiliar adults in 2+ ways:
- Reduced or absent reticence in interacting with unfamiliar adults
- Age and culturally inappropriate verbal or physical behavior
- Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings
- Willingness to go off with an unfamiliar adult
Explain the etiology of PTSD and ASD
Hyperresponsive amygdala (fear)
• Under-responsive prefrontal cortex
(failure to inhibit fear)
- Reduced volume and dysfunction of hippocampus (impaired memory consolidation – dissociation?)
- Likely underlies the intrusive symptoms, alterations in arousal and reactivity, and impaired executive function seen in these disorders
Explain RAD and DSED etiology
• A direct result of pathogenic care in early childhood (under 5 years old):
– Social emotional neglect
– Repeated changes in adult caregiver
• Health and well-being of caregivers impacts child well-being:
– Current caregiver stressors, such as economic challenges
• Low SES = increased risk of emotional-behavioral problems in children
– Caregiving paradigm shaped by past experiences
• Abused caregivers more likely to have children who are abused/neglected
How do we treat PTSD and ASD?
Psychotherapy:
• Supportive therapy offering safe environment to express feelings
• Behavioral therapy to address specific problematic behaviors (e.g., avoidance behavior)
Medications:
• Antidepressants (SSRI first-choice, e.g., Sertraline)
How is adjustment disorder treated?
Provision of skills to improve coping
- Psychotherapy to learn coping mechanisms
- Involvement in support groups
- Psychotropic medications (severe cases)
- Hospitalization (severe cases’
What are the main dissociative disorders?
• DissociativeAmnesia
• Dissociative Identity Disorder
• Depersonalization/Derealization disorder
Dissociation: Splitting off from conscious awareness an aspect of cognition that helps to create a sense of self-identity (e.g., a memory)
A “last ditch” effort to respond to
overwhelmed coping mechanisms
What are the types of dissociative amnesia diagnosis ?
Memory loss for autobiographical information not caused by
another disorder
• Localized: Total loss of personal memory during a circumscribed period of time
- Selective: Some limited recall of personal memories during a circumscribed period of time
- Generalized: Loss of personal memory of entire life up to and including triggering event
What is dissociative fugue?
Specify if amnesia is “with dissociative fugue”
• Fugue: Purposeful travel or bewildered wandering associated
with amnesia for identity or other autobiographical information
• Typicalfeaturesoffugue: § Brief (hours to days) § Unobtrusive lifestyle during fugue § Spontaneous termination of amnesia § Rarely recurs
What is the key amnesia differentials?
Key Amnesia Differential: During a Mental Status Exam, identify the type of memory problem exhibited:
- If biological: Patient will have difficulty learning new information (anterograde memory loss) in addition to past memory loss
- Ifpsychological(dissociative):Patient learns new information well;only past memory loss (retrograde memory) will be present
Explain dissociative identity disorder diagnosis
1) Disruption of individual identity characterized by 2+ distinct personality states:
• The Primary (host)
• An Alter
2) Inability to recall personal information (as evidenced by
frequent memory gaps in the Primary personality while an alter takes control)
Explain depersonalization/derealization disorder diagnosis
Either (or both) of the following:
- Depersonalization: Experiences of unreality, detachment or being an outside observer of one’s thoughts, feelings, sensations, body or actions
- Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., objects and/or environment seem unreal or dreamlike)
What are the additional criteria of depersonalization/derealization disorder?
Reality testing remains intact (i.e., the person knows the perceptual experience is just a misperception)
Additional Criteria:
§ Symptoms result in functional impairment
§ Symptoms are not due to physiological effects of a substance or another medical condition (e.g., seizures)
§ Symptoms are not better explained by another mental disorder, such as panic disorder, acute stress disorder, PTSD, or another dissociative disorder
What is the etiology of Dissociative disorder etiology?
- Currently unknown
- Amnesia: no known structural brain damage accounting for memory loss
- Primarily a dysfunction of the process of retrieving memories
- A “last ditch” effort to respond to overwhelmed coping mechanisms
What are the correlations of DID?
• DID = smaller volumes: – Hippocampus – Amygdala – Parietal structures (perception and personal awareness) – Frontal structures (executive functioning)
• Associated with DID symptoms:
– Dissociation
– Neurotic defense
mechanisms
• Meta-analysisofn=3 studies with DID patients, non-DID patients, controls (HC):
– DID + PTSD = smaller hippocampi bilaterally
– DID = smaller left hippocampi vs. PTSD patients
– DID trend for smaller right hippocampi vs. PTSD patients (p = 0.06).
– Amygdala comparison not possible (no data)
• DID=smallerhippocampi beyond changes in PTSD
• Neuroanatomicalevidence for memory impairment between host and alters?
How do we treat dissociative disorders?
- Usually, psychotherapy supported by a strong therapeutic alliance
- Hypnosis may be used to help recover memories
- Memory retrieval may trigger grief, rage, shame, guilt, depression and inner turmoil
What is persistent grief disorder?
‒ Only diagnosed if 12+ months since death of a close person
‒ Since the death, 1+ months of clinically significant bereavement
symptoms almost daily:
- Intenselongingand/orpreoccupationwiththoughtsofthedeceased
person AND - Multipleadditionalsymptomsrelatedtothedeathsuchas:
‒ Identity disruption (feeling part of self has died)
‒ Disbelief about the death
‒ Avoidance of reminders that person is dead
‒ Intense emotional pain
‒ Difficulty re-engaging in relationships/activities ‒ Emotional numbness
‒ Feeling life is meaningless
‒ Intense loneliness
‒ Symptoms not explained by major depressive disorder or other mental disorder
