Chapter 7: PTSD, dissociative disorders, and somatic symptom disorders

LIFETIME PREVALENCE OF SPECIFIC TRAUMATIC EVENTS AND PROBABILITY OF DEVELOPING PTSD AFTER THE EVENT

- Rape: 5.4% in population - 49% chance of PTSD (very high probability of getting PTSD) - Other sexual assault: 6.2% - 24% chance of PTSD - Badly beaten up: 11.4% - 32% chance of PTSD - Natural disaster: 16.6% - 4% chance of PTSD - Mugged/threatened: 25% - 8% chance of PTSD - Serious Car Crash: 28% - 2% chance of PTSD - Witnessed killing/serious injury: 29% - 7% chance of PTSD - Sudden unexpected death: 60% - Before crit A is changed (this is still included) - Any trauma: 89.6% - - ^^ Figure 7.1 in textbook: - Left: green: probability person has experienced the event - Right: % of getting PTSD - ^^ what is unique about these experiences -

ACute stress disorder (ASD)

- A less intense reaction to trauma, compared to PTSD, with similar symptoms - During or after the event, 3 or more dissociative symptoms (e.g., numbing or detachment; being in a daze; derealization; depersonalization or amnesia for aspects of the event) - Lasts from 3 days to one month - If symptoms persist beyond 4 weeks, consider diagnosis of PTSD - ^^^ basically short term PTSD - after 1 month= PTSD

ASD vs. PTSD

- ASD last no longer than a moth, PSTA begins at least a month after trauma - both: intrusive reexperiencing, avoidance of reminds of trauma, increased arousal or reactivity, negative mood or thoughts, dissociation

three faces of eve

- Based on a true story - Real patient's name was Chris Sizemore, whose identity was revealed to public in 1975 - Book by Corbett Thigpen and Hervey Cleckley - Joanne Woodward (as Eve White/Eve Black) - Academy award for best actress (1957) - Lee J. Cobb (as her psychiatrist, Dr. Luther

METIN BASOGLU AND PTSD IN SURVIVORS OF TORTURE IN TURKEY

- Compared 55 tortured political activists; 55 not tortured activists; 55 people with no history of activism or torture - Activist tourtured - Among those tortured, 36% had PTSD at some stage (moderately severe - no severe PTSD) - Perceived severity of torture related to severity of PTSD but not to anxiety or depression - Lack of social support predicted anxiety and depression, but not PTSD - People are likely to get better if they have good social support, but this is opposite to that - Support helps w/ an or dep (not other ptsd) - Active coping responses may have reduced the traumatic effects of uncontrollable stressors during torture - Inability to find a meaning for the trauma is an important factor in PTSD - People who could make meaning from experience (social cause or value to society) = less likely to have PTSD - There are many psychological variables why some people have ptsd and others don't = when we know more about this = helps with treatment - The trauma memory, including emotional elements, must be repeatedly activated and modified (dissociative strategies interfere with this process)

PTSD DSM-5

- DSM-5 - New chapter in DSM-5: Trauma and Stress Disorders - Used to be anxiety disorder - PTSD - Acute Stress - Adjustment disorder - Previously (in DSM-IV): PTSD was considered to be an anxiety disorder - vets from Vietnam= prompt the field - much attention to this (also Iraq)

BACKGROUND ISSUES AND CONTROVERSIES

- For years, soldiers were viewed as being weak if they developed emotional problems following traumatic combat experiences (thus reluctant to report) - Flip side of that argument may be that those who are resilient following loss of a loved one may be seen as cold or uncaring - George Benano - People who are resilient in face of loss= stigma of being robotic/ something is wrong with you - Open field how people respond to loss/ react to events - HBO The Pacific ep about PTSD - Entire ep about this = public attitudes change - PTSD introduced to the diagnostic manual with DSM-III (1980) based on soldiers returning from the war in Vietnam - OR: combat - Also experiences of rape victims became the focus of treatment - Also in DSM 3 - Breadth of the diagnostic category was inadvertently expanded ("bracket creep") over the next 30 years with emphasis on subjective response to threat - Nature of trauma was expanded: robbery and other kinds of events - Ask Q: have you unexpected learned about death of loved one - Should this be included - Not just loss, but nature of loss - Point: if you are trying to understand PTSD, and you want to understand strong emotional reaction to severe emotional events, you cannot really make the experience heterogeneous assumptions - PTE: potentially traumatic event: talking to people who have these events (9/11, combat, ...) - These are homogeneous groups of people - Good for the nature of the event to be tightened - PTSD: only category where particular kind of event is in the diog. - ^^^ by far most complex diog crit in DSM - not just 5 out of 9 - dev of this: not part of the DSM

dissociative identity disorder

- Formerly known as Multiple Personality Disorder - 2 or more personalities (2 different kinds of styles, also don't remember persiods of time acting as one or the other - some are aware of the other, some are not - Formerly known as "Multiple Personality Disorder" - Existence within the person of two or more distinct personalities - Each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self - At least 2 of these personalities recurrently take control of the person's behavior - Inability to recall important personal information - case study: thought she had a drinking problem, but he didn't initially believe in DID - Sybil: now know that sybil was a hoax - not diagnostic criteria in DSM, signs for therapists - Time distortions or time lapses - Being told of doing things that person does not remember - Changes in behavior noted by a reliable observer - Use of the world "we" in the course of an interview - Discovery of writings or drawings that the person does not remember producing - History of severe headaches, especially if accompanied by blackouts, seizures, or dreams - 3 faces of EVe - child, life - seductive, - claim to have 15-20 personalities - be careful about diagnosing - conditions associated with DID - Being easily hypnotized - Sexual and physical abuse as a child - misdagisnoesed as DID - mruders in LA, and bodies were found on hillside, stopped and then murdered again in Oregon - while he was under hypnosis: had another person come up "Steve" - lawyer pleads insanity - other people said he was feinging hypnosis - Malingering (e.g. Kenneth Bianchi, aka "The Hillside Strangler") - DANGERS OF GOING TO DID TOO FAST - Feigned symptoms adopted consciously in order to avoid responsibility - Psychotic disorders (e.g., schizophrenia) - Partial dissociation or shifts in emotions and behavior that do not warrant a diagnosis of DID

DISSOCIATIVE EXPERIENCES SCALE (SAMPLE ITEMS)

- How often have you experienced the following? - (common) Suddenly realizing, when you are driving a car, that you do not remember what was happening during all or part of the trip. - (rare) Finding yourself dressed in clothes that you do not remember putting on. - (most rare) Being approached by people you do not know who call you by another name and insist that they know you.

SIMILARITIES TO DISSOCIATIVE DISORDERS

- Inability to recall important aspects of the trauma - Feeling detached - Best predictors (moderate strength) of PTSD from events at the time of trauma are dissociative experiences - Symtoms after event look mire like diss. That predict pTSD

NEGATIVE CHANGES IN MOOD / COGNITION CLUSTER (2 or more)

- Inability to remember an important aspect of the traumatic event - Main part to move PTSD away from anxiety - Extreme negative reactions look like anxiety : gad= does not have to do w/ inability to remember (PTSD: between anxiety and diss. - Persistent and exaggerated negative beliefs or expectations about oneself, others, and the world (e.g., I am bad, no one can be trusted, the world is completely dangerous) - Persistent distorted cognitions about the cause or consequences of the traumatic event that lead the person to blame self or others - Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) - Markedly diminished interest or participation in significant activities - Feelings of detachment or estrangment from others - Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or loving feelings) **- Case study: PTSD from rape - Show this cluster

PTSD DSM def

- Intrusive symptoms associated with the event (e.g., memories, dreams) - Persistent avoidance of stimuli associated with the traumatic event - Negative alterations in cognitions and mood associated with the event - Marked alterations in arousal and reactivity associated with the event - ^^ clusters have own description - Duration: >1 month - Significant distress or impairment in functioning - Specify if with dissociative symptoms (depersonalization / derealization) - Depersolization: outside body; watching self - Deralization: feel like things aren't real

PTSD CRITERIA INCREASED AROUSAL CLUSTER 4 (2 or more of the following)

- Irritable behavior and angry outbursts - Reckless or self-destructive behavior - Hyper-vigilance - Exaggerated startle response - Problems with concentration - Sleep disturbances

causes: biological

- MZ tiwns had a higher concordance rate for exposure to combat than DZ twins - hgiher concordance for PTSD than fraternal twins too - genes contribute to arousal symtoms and not to reexperienceing, level of combat exposure predicted reexperiencing - people with PTSD show differences in the functioning, structure of amygdala and hippocampus - experience of heightened fear reactivity and intrusive memories - sympathetic nervous system is aroused and the fear response is sensitized in PTSD - smaller than average hippocampus, but correlations, not caused

tHE RECOVERED MEMORY CONTROVERSY

- New arguments regarding repression - Freud noted that many of his hysterical patients reported sexual abuse during early childhood - He eventually decided they were childhood fantasies resulting from unconscious wishes (the Oedipal conflict) - 70s-80s notion of repressed memories, actively forget things that would happen to them - courage to heal: repressed memories are common, anyone who comes into therapy is suffering form childhood trauma - An example of an inflammatory position on the recovered memory controversy. They said: - "You may think you don't have memories, but often as you begin to talk about what you do remember, there emerges a constellation of feelings, reactions, and recollections that add up to substantial information. To say, 'I was abused,' you don't need the kind of recall that would stand up in a court of law." - "Often the knowledge that you were abused starts with a tiny feeling, an intuition. It's important to trust that inner voice and work from there. Assume your feelings are valid. So far, no one we've talked to thought she might have been abused, and then later discovered that she hadn't been. - not to say people haven't been abused, but they are brainwashing clients, telling everyone they ere abused - memories of challenger disaster - Interviews 1 day after the explosion and then again 3 years later, how you found out about the explosion - One third reported vivid, grossly inaccurate memories - during therapy people remember theses things they are vivid, they have to be real, BUT MANY POEPLE REPORTED VIVID MEMORIES BUT THEY WERE WRONG

DID treatment

- No strong research support - General Tendencies - Promote integration of personalities (don't talk to each one) - Emotionally process known trauma - Use of hypnosis (to facilitate recovery of memories, but it most often strongly discouraged because it can exacerbate dissociation) - Don't use names for different personalities (encourages dissociation) - bliss theory - Vulnerability takes the form of being extremely hypnotizable - Exposure to repeated, severe abuse - Person uses self-hypnosis to avoid emotional experience, protect oneself from emotional trauma - Eventually loses control of trance states humphrey model: Argues other way around from Bliss' model Most people have a fictional unified self This "head of state" gives the appearance of unification despite differing voices and changes over time People with DID, for some reason, do not develop the same single head of state model of personality Not much direct research support for either model (because there's not much research)

frequency of PTSD/ASD

- PREVALENCE - U.S. Lifetime prevalence rate: 6.8% - Prevalence: crit have changed over years= be cautious about number - Epidemiology: totally structured interview= no follow up room = very complex disorder= be cautious - Only some people who experience trauma go on to develop PTSD - Approximately 50% of adults have experienced a traumatic event - Some people with trauma don't get ptsd - 10% of women and 5% of men experience PTSD (lifetime), even though it has been found that men are more likely to be exposed to traumatic events - fem= higher - nature of events for fem are different - trauma is not random - men, young people with history of donctu disorders, extroverts ore lilkey to experience trauma, risky behavior, people who are anxious, family history of mental illness, more trauma - those who are anxious more likely develop PTSD after trauma, meet other disorders as well if they have PTSD more likely to develop another disorder too

Changes from DSM-IV to DSM-5

- PTSD now includes 4 rather than 3 symptom clusters - Criterion A is now more explicit about what qualifies as traumatic experience - Eliminated Criterion A2 (subjective reaction to event ec horror) - Get rid of hwo you respond: respond w/ fear and horror - This was very subject and depended on the way the person describes process - Avoidance / numbing is divided into 2 distinct clusters: avoidance and persistent negative alterations in cognitions and mood - Acute Stress Disorder, dropped Criterion A2 regarding subjective reaction to traumatic event ("experiencing fear, helplessness, or horror") - Adjustment disorders, re-conceptualized as stress-response syndromes - Reactive Attachment Disorder and Disinhibited Social Engagement Disorder (split into two categories from previous one) - Disengagement

derealization/depersonalization

- Persistent feeling of being detached from yourself; feeling as if you are in a dream; being an outside observer with respect to your own thoughts, feelings, sensations, and body - Experiences of unreality or detachment with respect to surroundings (e.g., other people are experienced as being unreal, dreamlike, foggy, or lifeless)

PTSD Cluster: intrusive symptoms

- Recurrent, involuntary, and intrusive distressing memories of the event - Recurrent distressing dreams (nightmares) in which the content and / or affect of the event are related to the traumatic event - Dissociative reactions (e.g., flashback: sudden memories during which trauma is replayed in images or thoughts ) in which the person acts or feels as if the traumatic event were recurring - Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event - Marked physiological reactions to internal or external cues that symbolize or resemble some aspect of the traumatic event - - must have one or more^^^^

dissociative amnesia

- Sudden ability to recall extensive and important personal information (with sudden, unexpected travel away from home, it used to be called "dissociative fugue": move away from home) - follows a traumatic event -A reversible inability to retrieve memories (retrograde amnesia) Usually of a personal nature Often limited to events that occur in circumscribed period of time (hours) The diagnosis applies to gaps in recent memories rather than loss of childhood memories Usually follows a stressful event (accident, abuse, suicide attempts, combat)

dissociative disorders

- controversial: some people think it doesn't exist, therapist accidentally suggests it to clients - his idea: it happens, but is rare - Defining Feature: Disruption in the usually integrated functions of consciousness, memory, and identity - One or more "parts" are left out of this chain - used to be called multiple personality disorder - Like PTSD, often appear following traumatic events - Example: Case of "Dave" from UVa - missing time for sick days, i have changes in mood: today i'm the happy dave, i was the angry dave, - i have the kind of DID where there is no disturbance in consciousness: nOT REAL YOU CAN'T HAVE DID THIS WAY - The distinction between conscious and unconscious aspects of the mind (or "automatic and controlled" cognitive processes; or explicit and implicit memory) - Good analogue condition is hypnosis (also controversial) - disturbance in consciousness: multiple levels of conscious experience, dissociative state: one of those levels is separated from the others - driving cross country, autopilot - disrutpion in the communication among and switching between levels of consciousness

causes: psychological

- dissociation predicts more, not less PTSD - preparedness, purpose, absence of blame can aid coping with trauma, - learn to enhance and suppress emotion, - emotional processing: engage emotionally with trauma, victims articulate/organize chaotic experience, victims believe that despite the trauma, world is not a terrible place - meaning marking: eventually finding some value or reason for having endured trauma - may involve religion, renewed appreciation for life or public service, search for meaning is associated with more PTSD symptoms, finding meaning is linked to better adjustment, - postraumtic growth: positive changes resulting from trauma, linked with less depression and more positive well being - integration and laternative pathways: trauma exacerbates or reveals a preexisting disorder, in most cases ASD or PTSD develop as a result of combination of factors, including trauma, personality characteristics that predate trauma, exposure during trauma, emotional processing and osical support afterwards, resilience more common outcome following trauma

traumatic stress:

- is defined in DSM-5 as an event that involves actual or threatened death, serious injury, sexual violence to self, death, witnessing others experience trauma, learning loved ones are traumatized, details of trauma - rape, military combat, bombing, airplane crashes, earthquakes,

comorbidity

- many people with ptsd also have other disorder, dispersion, anxiety, drug abuse - headahces, anger, sucidal

course and outcome

- numbing, depersonalization, sense of reliving the experience best predictors of future PTSD - symptoms dimisih over time, rapidly in first year a gradually after, fast for those with treatment, 1/3 of people report symptoms after 10 years, - 40 years after war, 10% no recovery, holocaust

graph on george

- shows dist of different kinds of responses (hypothetical) - bottom: resilience: - in group of resilience people= show small reaction to traumatic events - some people have very serious neg reaction, but then recovery - delayed response: fine after, but get worse - chronic: people upset across the board - small number of people - ^^ try to see the different personalities

predicting PTSD from ASD

- walk through symptoms of people in waiting period - reliving experience/ depersonalization: associated with high prob that you will meet crit for PTSD - see that it looks diss. Disorders

PROBABILITY OF PTSD AS A FUNCTION OF SEVERITY AND PROXIMITY TO EVENT

DATA FROM 9/11 TERROR IN NYC (Bonanno et al. 2006) - Interviewed representative sample of 2,752 New Yorkers in months following the attack - Chronic PTSD prevalence was 6% - Among those physically injured in the attack, it went up to 26% - Rate also influenced by whether you had a friend or relative in the building

Old Description of the TRAUMATIC EVENT in DSM-IV

Direct exposure Person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others Witnessing (in person) Indirectly learning that a close friend or relative was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental Repeated or extreme indirect exposure to aversive details of the event (usually in the context of professional duties - e.g., military, first responders) Person's response involved intense fear, helplessness, or horror

new description of trauma

Directly experiencing the traumatic event Witnessing (in person) the event as it occurred to others Learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or accidental. Experiencing repeated or extreme exposure to aversive details of the traumatic event (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse) Note: - First responders or police - ^ the more tight def

GEORGE BONANNO: RESILIENCE TO LOSS AND POTENTIALLY TRAUMATIC EVENTS

Emphasizes individual differences in response to event - Some people are overwhelmed; others struggle for months and then gradually recover; some manage to continue to function at normal levels in spite of the experience and appear resilient; and some show a delayed onset of problems - He's focused on individual differences and prediction of resilient outcomes over time - Most people respond to even the most extreme stressors with minimal disruption of overall functioning - That is resilience - In contrast, 5 to 10% do develop PTSD or other long-term problems such as chronic grief - Small number of people have full blown ptsd - Has studied response to various kinds of PTEs, including serious injuries, illness, loss of close relatives, exposure to combat

EDNA FOA'S MODEL OF EMOTIONAL PROCESSING

Frequency and intensity of symptoms go down over time 94% of rape victims meet PTSD symptom criteria at 14 days; 64% three weeks later; 47% eleven weeks after initial assessment PTSD people and non-PTSD people get better during first month (post-trauma) but the PTSD people show no further improvement People who don't get better are also the ones who experience early dissociation Foa says "emotional processing" is impaired in people who don't show natural decline of symptoms after trauma The trauma memory, including emotional elements, must be repeatedly activated and modified (dissociative strategies interfere with this process) - Thinks that if person is avoidant and has diss symp= gets in way of getting over it - Person therefore needs to find way to go through experience: reprocessing is important

dissociative fugue

Very rare First consider dementia, substance abuse, or malingering Extreme form is person moving away and establishing a new identity New identity is likely to be more gregarious and uninhibited than the person's usual personality

dissociative disorders in DSM-5

dissociative amensia, DID, despersonalizaiton/derealization disorder

treatment of PTSD

emergency help for trauma victims - critial incident stress debriefing, single 1-5 hour group meeting offered 1-3 days following a disaster, several phases where participants share their experiences and reactions, group leaders offer education, assessment and referral if necessary - not clear whether it reduces PTSD - CISD: harmful, unnatural, too much emotion too soon, - WWI: immediate treatment, proximity with battlefield, expectation of return upon recovery, 60% of soldiers recovered enough to return, treated on front lines less PTSD, - naturalistic intervention: soldies assigned to army's treatmnte as usual, battleind debriefing, battle mind training, finding inner strength in combat, all three good to reduce PTSD - cognitive behavior therapy for PTSD. most effective treatment is resxopusre - prolonged expsure: painful but it helps, - imagery rehearsal therapy, recerrent nightmares, - 50% of patients meet criteria after exposure, most strongly supported, beginning is the healing process - EMDR: eye movement desensitization and reprocessing, technique that has been greeted with enthusiasm and skepticism, rapid back and forth of eye movements reduced anxiety, exposure is the ingredient not eye movements - treatment of ASD" treatments last longer, target trauma victims that meet aSD, 5 90 minute sessinos - antidepressant meds: SSRIS, comorbidity of PSD and depression, only 30% of patients recover fully from PTSD symptoms, traditional anti anxiety MEDS ARE NOT EFFECTIVE FOR PTSD

PTSD: avoidance cluster

one or both of the following) - Avoidance of or efforts to avoids distressing memories, thoughts, or feelings about or closely associated with the traumatic event - Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event

causes of PTSD

social factors: -- Related to the experiences of trauma - Cannot only be the event bc some w/ trauma don't get it - More intense events increase the probability of developing PTSD - More intense = more likely - Figure 7.1 in textbook: - Left: green: probability person has experienced the event - Right: % of getting PTSD - Increased levels of social support are presumably associated with decreased probability of PTSD -book: - the nature of the trauma and the individual's level of exposure to it - availability of the social support following the trauma - more likely to develop PSTA when trauma is more intense, more exposure, if rape is completed, injured, life threatening, closer to 9/11 rash - lack of social support for vietnam veterans, not heroes, disdain, - prevalence of PTSD was 9x higher for o twins who served in vietnam and experience high levels of combat in comparison to identical twins who didn't serve