Trauma/Stressor-Related, Dissociative, and Somatic Symptom Disorders Flashcards
Trauma- and Stressor-Related Disorders:
All of the disorders in this category include exposure to a traumatic or stressful event as a diagnostic criterion.
Reactive Attachment Disorder:
This disorder involves a persistent pattern of inhibited and emotionally withdrawn behavior toward adult caregivers as demonstrated by (a) a lack of seeking or responding to comfort when distressed and (b) social and emotional disturbances that include at least two of the following: minimal social and emotional responsiveness to others; limited positive affect; unexplained irritability, sadness, or fearfulness when interacting with adult caregivers. For the diagnosis, the person must have a history of extreme insufficient care that’s believed to be responsible for his/her symptoms, have had an onset of symptoms before age five, and have a developmental age of at least nine months.
Disinhibited Social Engagement Disorder
this disorder involves a persistent pattern of behavior that’s characterized by inappropriate interactions with unfamiliar adults as demonstrated by at least two of four symptoms: reduced or absent reticence in approaching or interacting with strangers, overly familiar behavior with strangers, diminished or absent checking with adult caregivers after being separated from them, willingness to accompany a stranger with little or no hesitation. The diagnosis also requires that the person has a history of extreme insufficient care that’s believed to be responsible for his/her symptoms and a developmental age of at least nine months.
Posttraumatic Stress Disorder (PTSD):
The diagnostic criteria for PTSD differ slightly for adults, adolescents, and children over six years of age and children six years of age and younger. However, for individuals of all ages, symptoms must have lasted for more than one month, cause significant distress or impaired functioning, and be due to exposure to actual or threatened death, serious injury, or sexual violence. In addition, the symptoms for all age groups represent four types: intrusion (e.g., recurrent distressing memories of the event), persistent avoidance of stimuli associated with the traumatic event, negative changes in mood or cognition, and alterations in arousal and reactivity.
PTSD has been linked to several brain abnormalities: Neuroimaging studies have linked it to a hyperactive amygdala and anterior cingulate cortex, a hypoactive ventromedial prefrontal cortex, and a reduced volume of the hippocampus, with some studies finding increased activity of the hippocampus and other studies finding decreased activity (Averill, Averill, Akiki, & Abdallah, 2021; Murray, Keifer, Ressler, Norrholm, & Jovanovic, 2013). In addition, there’s evidence that the ventromedial prefrontal cortex ordinarily inhibits activity of the amygdala but, in PTSD, reduced activity in the ventromedial prefrontal cortex reduces inhibitory top-down control of the amygdala, resulting in an exaggerated fear response (e.g., Levin, Scheibel, Troyanskaya, Thompson, & Henson, 2019). There’s also evidence of abnormalities in several neurotransmitters including increased levels and activity of dopamine, norepinephrine, and glutamate and decreased levels and activity of serotonin and GABA (Sherin & Nemeroff, 2011).
In terms of treatment, APA’s (2017) Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults provides recommendations for psychological and pharmacological treatments. With regard to psychological treatments, it gives (a) a strong recommendation for cognitive-behavior therapy, cognitive processing therapy (which combines challenging negative cognitions with writing and reading a detailed description of the trauma), cognitive therapy, and prolonged exposure, and (b) a conditional recommendation for brief eclectic psychotherapy, eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy. Note that research on EMDR has provided inconsistent results with regard to the effects of rapid eye movements: While some studies suggest that eye movements contribute to EMDR’s effectiveness, others suggest they are unnecessary for its beneficial effects (e.g., Harik, Hamblen, Norman, & Schnurr, 2018). Also note that single-session psychological debriefing, which is also referred to as critical incident stress debriefing and group psychological debriefing, has not been found to be effective and may actually worsen symptoms (e.g., Van Emmerik, Kamphuls, Hulsbosch, & Emmelkamp, 2002).
Most studies evaluating the use of telepsychology for treating PTSD have found it to be comparable to face-to-face interventions in terms of effectiveness. For example, in their systematic review of studies evaluating telepsychology for veterans with PTSD, Turgoose, Ashwick, and Murphy (2018) found that trauma-focused therapies (e.g., exposure therapy, behavioral activation) delivered via telepsychology or in-person were similar in terms of the reduction of PTSD symptoms, attendance and dropout rates, client satisfaction, and therapist fidelity to treatment protocols. However, the studies included in their review did not provide entirely consistent results with regard to the therapeutic alliance: While therapists providing telepsychology said they didn’t have trouble developing rapport with clients, some reported barriers to developing a therapeutic alliance, such as the inability to detect nonverbal communications.
The APA Clinical Practice Guideline does not address treatments for children and adolescents, but trauma-focused cognitive-behavior therapy is an evidence-based treatment that was initially designed for children and adolescents 3 to 18 years of age who have experienced sexual abuse and has subsequently been used to treat children and adolescents exposed to other types of trauma. It incorporates family therapy, parenting skills training, and conjoint parent-child therapy.
Finally, with regard to pharmacological treatments for adults, the Clinical Practice Guideline gives a conditional recommendation for the SSRIs fluoxetine, paroxetine, and sertraline and the SNRI venlafaxine. These drugs are useful for treating the depression that often accompanies PTSD and may alleviate the core symptoms of re-experiencing, avoidance/numbing, and hyperarousal (Khouzam, 2013).
Acute Stress Disorder:
: Like PTSD, the diagnosis of acute stress disorder requires exposure to actual or threatened death, severe injury, or sexual violation. The person must also have at least nine symptoms from any of five categories (intrusion, negative mood, dissociative symptoms, avoidance, arousal), and symptoms must have lasted for three days to one month and cause significant distress or impaired functioning.
Dissociative Disorders
The DSM-5 describes the disorders in this category as involving “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 291).
- Dissociative Amnesia: This disorder involves an inability to recall important personal information that cannot be attributed to ordinary forgetfulness and causes significant distress or impaired functioning. Amnesia takes one of the following forms, with localized amnesia being most common: localized (an inability to recall all events that occurred during a circumscribed period of time), selective (an inability to recall some events that occurred during a circumscribed period of time), generalized (a complete loss of memory for one’s entire life), systematized (a loss of memory for a specific category of information), and continuous (an inability to remember new events as they happen). A specifier is used to indicate if the disorder includes dissociative fugue, which is purposeful travel or purposeless wandering that’s associated with the loss of memory. Dissociative amnesia is often related to victimization or exposure to a traumatic event.
- Depersonalization/Derealization Disorder: The diagnosis of this disorder requires persistent or recurrent episodes of depersonalization (a sense of unreality, detachment, or being an outside observer of one’s thoughts, actions, etc.) or derealization (a sense of unreality or detachment with regard to one’s surroundings) accompanied by intact reality testing and significant distress or impaired functioning.
Somatic Symptom and Related Disorders:
These disorders involve physical symptoms and/or health-related concerns that cause significant distress or impaired functioning.
. Somatic Symptom Disorder:
Somatic Symptom Disorder: This disorder involves one or more somatic symptoms that are distressing or cause a significant disruption in daily life and are accompanied by excessive thoughts, emotions, or behaviors related to the symptom(s) or associated health concerns as indicated by the presence of at least one of the following: disproportionate or persistent thoughts about the seriousness of the symptoms, a persistently high level of anxiety about health or symptoms, excessive time and energy spent on health concerns or symptoms. Specifiers are used to indicate if symptoms are mild, moderate, or severe, involve predominant pain, and are persistent (are severe, have caused marked impairment, and have lasted more than six months).
Illness Anxiety Disorder:
This disorder involves a preoccupation with having a serious illness with no or mild somatic symptoms, excessive anxiety about health, and either excessive health-related behaviors or avoidance of health care. Symptoms must be present for at least six months, although the nature of the symptoms may vary over time.
Conversion Disorder (Functional Neurological Symptom Disorder):
This disorder is characterized by one or more symptoms that involve a disturbance in voluntary motor or sensory functioning (e.g., paralysis, blindness). For the diagnosis, symptoms must be incompatible with any known neurological or medical condition and cause significant distress or impaired functioning. Specifiers are used to indicate symptom type, the course of the disorder (acute or persistent), and the presence or absence of a psychological stressor. Note that conversion disorder can involve psychogenic non-epileptic seizures (PNES) that resemble true epileptic seizures in terms of behavioral symptoms but are not accompanied by the brain electrical activity associated with epileptic seizures and that video EEG is often used to identify PNES. It involves simultaneously recording a person’s brain electrical activity with an EEG and overt behaviors on video. When the person’s seizure-like behaviors are due to PNES, the EEG pattern does not correspond to the behaviors because they are not being caused by abnormal brain electrical activity (Alsaadi & Shahrour, 2015).
- Factitious Disorder:
The DSM-5 distinguishes between factitious disorder imposed on self and factitious disorder imposed on another. Individuals with factitious disorder imposed on self falsify or induce physical or psychological symptoms that are associated with a deception (e.g., ingestion of a drug to produce abnormal lab results). They present themselves to others as being ill or impaired and engage in the deception even when there’s no obvious external reward for doing so. Factitious disorder imposed on another has the same symptoms except that they’re induced in another person (often in a child by his/her mother).
Factitious disorder must be distinguished from malingering, which is included in the DSM-5 with Other Conditions That May Be a Focus of Clinical Attention. It involves an intentional production of physical or psychological symptoms for the purpose of obtaining a drug, financial compensation, or other external reward. According to the DSM-5, “malingering is differentiated from factitious disorder by the intentional reporting of symptoms for personal gain … [while] the diagnosis of factitious disorder requires the absence of obvious rewards” (p. 326). The DSM-5 also states that malingering should be suspected whenever a person seeks a medical evaluation for legal reasons, there’s a marked discrepancy between the person’s symptoms and objective findings, the person is uncooperative with evaluation or treatment, and/or the person has antisocial personality disorder. The forced-choice method has been found useful for detecting malingering and involves presenting the person with test items that require him/her to choose the correct answer from two or more alternatives. The use of this method is based on the assumption that people who are malingering will answer items incorrectly at a higher rate than would be expected by chance alone. For instance, when each item has two alternative answers (e.g., true or false), malingering is suggested when the person answers more than 50% of the items incorrectly.
Feigned memory loss associated with factitious disorder and malingering must be distinguished from genuine memory loss that’s due to traumatic brain injury or other condition (Jelicic & Merckelbach, 2015): For people with genuine memory loss, the beginning and end of the amnestic period are gradual and hazy and these individuals often remember fragments of some events that occurred during that period. In contrast, for people with feigned memory loss, the onset and termination of the amnestic period are often sudden, and these individuals do not remember any events that occurred during this period. Also, in contrast to people with feigned memory loss, those with genuine memory loss often believe that hints or clues will help them recall their lost memories. Finally, several tests can be used to help detect malingering. For example, the Test of Memory Malingering (TOMM) was developed specifically to determine if an individual is feigning memory loss. It uses a forced-choice format that requires individuals to respond to items by indicating which of two images was presented to them just prior to testing. Individuals who are malingering perform significantly below chance level (below 50% correct), which indicates they deliberately chose wrong answers. Malingering is also suggested when individuals exhibit excessive impairment or an unexpected pattern of responding (e.g., a pattern that’s atypical for individuals with genuine impairment) on neuropsychological tests.
