7/3/2013 ABNORMAL PSYCHOLOGY SEVENTH EDITION CHAPTER SEVEN CHAPTER OUTLINE

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1 ABNORMAL PSYCHOLOGY SEVENTH EDITION Oltmanns and Emery PowerPoint Presentations Prepared by: Ashlea R. Smith, Ph.D. This multimedia and its contents are protected under copyright law. The following are prohibited by law: any public performance or displays, including transmission of any image over a network, preparation of any derivative work, including the extraction, in whole or in part, of any images, any rental, lease, or lending of the program. CHAPTER SEVEN Acute and Postraumatic Stress Disorders, Dissociative Disorders, and Somatoform Disorders CHAPTER OUTLINE Acute and Posttraumatic Stress Disorders Dissociative Disorders Somatoform Disorders 1

2 OVERVIEW Traumatic stress disorders, dissociative disorders, and somatoform disorders look different, but share an important similarity: dissociation the disruption of the normally integrated mental processes involved in memory, consciousness, identity, or perception. A controversial area in psychology Traumatic stress disorders are the least controversial Traumatic stress Defined in the DSM-IV-TR as an event that involves actual or threatened death or serious injury to self or others and creates intense feelings of fear, helplessness, or horror Acute Stress Disorder (ASD) Occurs within four weeks after exposure to a traumatic stress and characterized by dissociative symptoms as well as: Reexperiencing, avoidance of reminders, and marked anxiety or arousal Posttraumatic Stress Disorder (PTSD) Defined by symptoms of reexperiencing, avoidance, and arousal, but PTSD is either longer lasting or has a delayed onset. 2

3 The defining symptoms of both acute and posttraumatic stress disorder include: 1. Reexperiencing 2. Avoidance 3. Persistent arousal or anxiety Dissociative symptoms are common in the immediate aftermath of a trauma; they must be present for the diagnosis of ASD, but not for PTSD (Frances, First, & Pincus, 1995). REEXPERIENCING Repeated, distressing images or thoughts Intrusive flashbacks Horrifying dreams Dissociative state AVOIDANCE Attempts to avoid thoughts, feelings related to the event Avoid people, places, or activities that remind them of the event Numbing of responsiveness AROUSAL OR ANXIETY Predicts a worse prognosis (Schell, Marshall, & Jaycox, 2004) Hypervigilance Restlessness, agitation, and irritability Exaggerated startle response DISSOCIATIVE SYMPTOMS Dazed and act spaced out Depersonalization Derealization Dissociative amnesia 3

4 Diagnosis of ASD and PTSD Brief historical perspective Maladaptive reactions to trauma have long been an interest to the military. Shell shock or combat neurosis (Jones, Thomas, & Ironside, 2007) Vietnam War prompted much interest in PTSD due to delayed reactions to combat being very common (Figley, 1978). What Defines Trauma? DSM-IV-TR defines trauma as: The experience of an event involving actual or threatened death or serious injury to self or others. A response of intense fear, helplessness, or horror in the reaction to the event. Different traumas also have unique psychological consequences. The effect of exposure to disasters is a particular concern due to large numbers impacted. Why is trauma no longer defined as outside of the usual human experience? Many people suffer from ASD symptoms following a trauma. Many traumatic stressors are a common part of the human experience. 4

5 Disaster and Emergency Workers Not immune to trauma s aftereffects Emergency workers are less than half as likely to develop PTSD as victims. Training, preparation, and sense of purpose appear to be protective. Hardiness Sense of commitment Control Challenge in facing stress Comorbidity High for depression, other anxiety disorders, and substance abuse Anger: usually very prominent; risk for suicide Frequency of Trauma, PTSD, and ASD Prevalence of PTSD 6.8% of people living in the United States 90% of people living in Detroit have experienced a trauma with 9% developing PTSD Most common cause: unexpected death of loved one 20%-40% of children develop PTSD FIGURES 7-1 Traumatic Events and the Risk for PTSD 5

6 Is the experience of trauma random? NO Many traumas do not occur at random due to risky behaviors. People who are anxious or who have a family history of mental illness also experience more traumas. Minorities who are more likely to live in dangerous environments due to socioeconomic factors are therefore more likely to be exposed to more traumatic stress. Figure 7-2 The Course of PTSD With and Without Treatment Causes and PTSD and ASD Social Factors in ASD and PTSD Victims of trauma are more likely to develop PTSD when the trauma is more intense. With less severe stressors, social support after a trauma can play a crucial role in alleviating long-term psychological damage. Biological Factors in ASD and PTSD Genetic contributions 6

7 Biological Effects of Exposure to Trauma People with PTSD show alterations in the functioning, and perhaps structure, of the amygdala and hippocampus. The sympathetic nervous system is aroused and the fear response is sensitized in PTSD. Does trauma change the brain? Differences between people with and without PTSD are correlations. Psychological Factors in ASD and PTSD Two-factor theory Classical conditioning creates fear when the terror of trauma is paired with the cues associated with it. Operant conditioning maintains avoidance by reducing fear (negative reinforcement); avoidance prevents the extinction of anxiety through exposure. The risk for PTSD depends on cognitive factors: preparedness, purpose and blame. The role of dissociation is debated: may not be adaptive, may be related to more PTSD Psychological Factors in ASD and PTSD (continued) Edna Foa Emotional processing Engage emotionally with trauma Articulation and organization of the chaotic experience Cognitive shift: the world is not a terrible place meaning making 7

8 Prevention and Treatment of ASD/PTSD Emergency Help for Trauma Victims Immediate support to trauma victims is a common goal of all early interventions. CISD no evidence that CISD prevents future PTSD, possibly harmful Three principles for combat soldiers that can applied to civilian disasters: 1. Immediate treatment 2. In the proximity of the battlefield 3. With the expectation to return to the front lines upon recovery Figure 7-3 Symptoms Among Soldiers Returning From Iraq CBT FOR PTSD The most effective treatment for PTSD is reexposure to trauma. Prolonged exposure Imagery rehearsal therapy Cognitive restructuring EMDR Francine Sharpiro Eye Movement Desensitization Reprocessing Includes rapid back-andforth eye movements Prolonged exposure appears to be the active ingredient 8

9 Antidepressant Medication Antidepressants and therapeutic reexposure are first-line therapies for PTSD. Effectiveness of SSRIs is likely at least partially due to the high comorbidity between PTSD and depression. Traditional antianxiety medications are not effective in treating PTSD (Golier, Legge, & Yehuda, 2007). Only 30% treated recover fully DISSOCIATIVE The symptoms of dissociative disorders are characterized by persistent, maladaptive disruption in the integration of memory, consciousness, or identity. Includes psychologically produced amnesia Confused travel long distances from home Existence of two or more personalities in one person Controversial and disbelieved by many DISSOCIATIVE Hypnosis: Altered State or Social Role? Debated as being a true state of dissociation Some assert that hypnosis works mostly on highly susceptible participants or people who are merely complying with a social role. Symptoms of Dissociate Disorders Dissociative identity disorder (DID) Depersonalization Dissociative amnesia Dissociative fugue 9

10 DISSOCIATIVE Diagnosis of Dissociative Disorders Contemporary Classification Four major subtypes Dissociative fugue»sudden and unexpected travel away from home with inability to recall details about the past and confusion about identity or assumption of a new identity Dissociative amnesia»sudden inability to recall extensive and important personal information that exceeds normal forgetfulness DISSOCIATIVE Diagnosis of Dissociative Disorders Contemporary Classification Four major subtypes (continued) Depersonalization disorder»feelings of being detached from oneself»like living in a dream ( as if feelings) Dissociative identity disorder»formerly known as multiple personality disorder Why should you doubt claims that dissociative identity disorder is common? 1. Most cases of dissociative disorders are diagnosed by a handful of ardent advocates. 2. The frequency of the diagnosis of dissociative disorders in general, and DID in particular, increased rapidly after release of the very popular book and movie Sybil. 3. The number of personalities claimed to exist in cases of DID has grown rapidly, from a handful to 100 or more. 4. Dissociative disorders are rarely diagnosed outside of the United States and Canada; for example, only one unequivocal case of DID has been reported in Great Britain in the last 25 years (Casey, 2001). 10

11 DISSOCIATIVE Causes of Dissociative Disorders Psychological Factors in Dissociative Disorders Little controversy that dissociative amnesia and fugues can be precipitated by trauma, specifically child abuse Trauma is suspected in DID, but much of the data is retrospective. The vast majority of trauma victims do not develop a dissociative disorder. DISSOCIATIVE Causes of Dissociative Disorders Biological Factors Little to no evidence of biological and genetic factors Social Factors Iatrogenesis: the manufacture of a disorder by its treatments Were cases were created by the expectations of therapists? DISSOCIATIVE Causes of Dissociative Disorders Treatment of Dissociative Disorders Hypnosis Abreaction Ultimate goal in treating DID is integration of the personalities 11

12 SOMATOFORM Symptoms of Somatoform Disorders Complaints about physical symptoms in the absence of medical evidence The problem is very real in the mind, though not the body Usually numerous, constantly evolving complaints such as chronic pain, upset stomach, dizziness Worry about a deadly disease despite negative medical evidence SOMATOFORM Diagnosis of Somatoform Disorders Conversion Disorder Symptoms mimic neurological disorders Make no anatomic sense Implies that psychological conflicts are being converted into physical symptoms Somatization Disorder History of multiple somatic complaints in the absence of organic impairments Eight symptoms, onset prior to age 30 FIGURE 7-4 Conversion disorder symptoms make no anatomical sense. In this figure pain insensitivity may be limited to one side of the face, but the nerves do not divide the face in half. 12

13 SOMATOFORM Diagnosis of Somatoform Disorders Hypochondriasis Fear or belief that one is suffering from a physical illness Much more serious than normal or fleeting worries and can lead to substantial impairment in life functioning Pain Disorder Preoccupation with pain At risk for developing dependence on pain medication SOMATOFORM BODY DYSMORPHIC DISORDER Preoccupation with some imagined defect in appearance Repeated visits to the plastic surgeon Exceeds normal worry about imperfections MALINGERING AND FACTITIOUS DISORDER Pretending to have a physical illness in order to achieve some external gain ($$$) Factitious disorder is motivated by a desire to assume a sick role SOMATOFORM Frequency of Somatoform Disorders Gender, SES and Culture More common among women (10 times) (Swartz et al., 1990) More common among lower SES Four times more common among African Americans and higher in Puerto Rico and Latin America Comorbidity Depression, anxiety, and antisocial personality disorder 13

14 SOMATOFORM Causes of Somatoform Disorders Biological Factors Diagnosis by exclusion Perils of this approach cases where some medical etiology can emerged later Psychological Factors Primary and secondary gain Cognitive tendencies: amplification, alexithymia FIGURE 7-6 Minor Physical Symptoms May Develop into a Somatoform Disorder SOMATOFORM Treatment of Somatoform Disorders Operant approaches to chronic pain Reward successful coping and adaptation (Kroenke, 2007) Cognitive behavioral therapy Cognitive restructuring Antidepressants Patients are likely to refuse a referral to a mental health professional. 14