7. Acute stress, PTSD, dissociative and somatic symptom disorders

Question 1

Trauma

Answer 1

“ Trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain and body. This imprint has ongoing consequences for how the human organism manages to survive in the present.” (van der Kolk, 2015, p. 21)

Question 2

Traumatic stress according to the DSM V

Answer 2

an event that involves actual or threatened death, serious injury, or sexual violence to self, or witnessing others experience trauma, learning that loved ones have been traumatized, or repeatedly being exposed to details of trauma.

Question 3

symptoms for both acute and posttraumatic stress disorder

Answer 3

• 1.Intrusive re-experiencing
• 2.Avoidance of reminders
• 3.Increased arousal or reactivity
• 4.Negative mood or thoughts
• 5.Dissociative symptoms

Question 4

Symptoms of ASD and PTSE

Answer 4

Intrusive re-experiencing
Avoidance
Negative mood/thoughts
Arousal or ractivity

Question 5

Intrusive re-experiencing

Answer 5

• Intrusive, distressing images or thoughts
• Flashbacks
• Horrifying dreams

Question 6

Avoidance

Answer 6

•Attempts to avoid thoughts, feelings related to the event
•Avoid people, places, or activities etc that are reminders
of the event

Question 7

Negative mood/thoughts

Answer 7

• Anhedonia
• Fear, anger, guilt
• Numbing of responsiveness
• Self blame
• Negative world view

Question 8

Arousal or reactivity

Answer 8

• Hypervigilance
• Restlessness, agitation, & irritability
• Exaggerated startle response

Question 9

The main symptom of trauma or PTSD and ASD

Answer 9

Dissociation

Question 10

Dissociation

Answer 10

• Argued to be the essence of trauma
• Overwhelming experience is split off and fragmented
• This includes all the various ways the survivor attempts to forget about the event (often these are not conscious). Lanius et al (2005): ‘A nonverbal
response to a traumatic memory.’
• Can include numbing, freezing, emotional constriction, cut off from
environment, also from body.
• Occurs on a continuum from mild (e.g. daydreaming, transitions
between sleep and waking) to extreme dissociative experiences where
the person becomes disconnected from reality

Question 11

Hormones during trauma

Answer 11

“As long as the trauma is not resolved, the stress hormones that the body secretes to protect itself keep circulating, and the defensive movements and emotional responses keep getting replayed.” (van der Kolk, 2014)

Question 12

Diagnosis of ASD - criterion A

Answer 12

A. Exposure to “trauma” (as defined by DSM-5)
1. Directly experiencing traumatic event
2.Witnessing event (in person) occurring to another
3.Learning the traumatic event occurred to a close relation
4. Experiencing repeated or extreme exposure to aversive details of
traumatic events (e.g. therapist exposed to details of child abuse)

Question 13

Diagnosis of ASD - criterion B

Answer 13

B. Presence of 9 or more sx from any of the 5 categories
•Intrusion
• Negative mood
• Dissociative symptoms
• Avoidance Symptoms
• Arousal Symptoms

Question 14

Intrusion symptoms of ASD in DSM 5

Answer 14

1. Recurrent, intrusive distressing memories
2. Recurrent distressing dreams
3. Dissociative reactions (e.g. flashbacks)
4. Intense or prolonged psychological distress or marked physiological reactions

Question 15

Negative mood symptoms of ASD in DSM 5

Answer 15

5. Persistent inability to experience positive emotions

Question 16

Dissociative symptoms of ASD in DSM 5

Answer 16

6. Altered sense of reality

7. Inability to remember important parts of traumatic event

Question 17

Avoidance symptoms of ASD in DSM 5

Answer 17

8. Efforts to avoid distressing memories, thoughts, feelings

9. Efforts to avoid external reminders

Question 18

Arousal symptoms of ASD in DSM 5

Answer 18

10. Sleep disturbance
11. Irritable behaviour and angry outbursts
12. Hypervigilance
13. Concentration problems
14. Exaggerated startle respons

Question 19

Required duration of trauma exposure for ASD

Answer 19

• Duration is 3days to 1month after trauma exposure

Question 20

Other criteria of ASD

Answer 20

• Causes clinically significant distress
• Not attributable to effects of substances or another medical condition
*Conceptually precedes PTSD
*Unnecessarily “confusing” (6 vs 9 symptoms)
*Normal vs abnormal reactions to abnormal event

Question 21

PTSD diagnosis criteria

Answer 21

A. Exposure to “trauma” (as defined by DSM-5)
B. Intrusion symptoms beginning after event (1 or more/5)
C. Persistent avoidance of stimuli associated with traumatic
event (1 or both/2)
D. Negative alterations in cognitions and mood (2 or more/7)
E. Marked alterations in arousal and reactivity (2 or more/6)
F. Duration of disturbance is more than 1 month (Criteria B, C, D, E)
G. Disturbance causes clinically significant distress or impairment
H. Disturbance not attributable to the physiological effects of a
substance or another medical condition

Question 22

Exposure to trauma requirement for PTSD

Answer 22

1. Directly experiencing traumatic event
2. Witnessing event (in person) occurring to another
3. Learning the traumatic event occurred to a close relation
4. Experiencing repeated or extreme exposure to aversive details of
   Traumatic events (e.g. therapist exposed to details of child abuse)

Question 23

Intrusion symptoms of PTSD

Answer 23

1. Intrusive, recurrent memories
2. Recurrent, distressing dreams
3. Dissociative reactions (e.g. flashbacks)
4. Intense or prolonged psychological distress at exposure to internal/external cues
5. Marked physiological reactions to internal/external cues

Question 24

Persistent avoidance of stimuli associated with traumatic event symptom of PTSD

Answer 24

1. avoidance/attempts to avoid distressing memories, thoughts, feelings
2. Avoidance or efforts to avoid external reminders (e.g. people/places)

Question 25

Negative alterations in cognitions and mood (2 or more/7) symptoms of PTSD

Answer 25

1. Inability to remember aspects of traumatic experience 2. Persistent negative beliefs about self, others, world 3. Persistent, distorted cognitions about event (blame self/others) 4. Persistent negative emotional state (e.g. anger, shame) 5. Markedly diminished interest in sig. activities 6. Feelings of detachment or estrangement from others 7. Persistent inability to experience positive emotions

Question 26

Marked alterations in arousal and reactivity (2 or more/6) symptom

Answer 26

1. irritable behaviour and angry outbursts 2. reckless or self-destructive behaviour 3. hypervigilance 4. exaggerated startle response 5. problems concentrating 6. sleep disturbance

Question 27

Frequency of trauma, PTSD and ASD

Answer 27

• estimates for PTSD worldwide vary around 6-8% (lifetime risk is ~9% in USA, DSM-5 ) • More common women (10% of females) than men (5% of males; why?) • Minorities are more likely experience PTSD (why?)

Question 28

Comorbidity of trauma, PTSD and ASD

Answer 28

* High for depression, other anxiety disorders, and substance abuse *What does this mean for our diagnostic system? * Anger – usually very prominent; Risk for suicide * ASD ➔ PTSD * Numbing, depersonalisation, re-living

Question 29

Risk factors of ASD and PTSD

Answer 29

• Nature of the trauma (intensity, frequency, type of trauma, age of trauma) • Lack of social support • Other stressful events afterwards (e.g., refugee experience of incarceration & uncertainty) • Personality vulnerability (anxiety) • Genetic contributions – not a lot of research around this (but also environment) – possibly epigenetics

Question 30

Complex trauma

Answer 30

Complex trauma occurs when the trauma is on-going, often in the context of a relationship which must be endured and managed – eg, child abuse, domestic violence

Question 31

Single event trauma versus complex trauma (or developmental trauma)

Answer 31

* Bessel van der Kolk (2012) has said that a single event is more likely to lead to the condition Post-Traumatic Stress Disorder (PTSD), and to the intrusive reliving of the event (sometimes called a ‘flashback’, drawn from terminology associated with psychotropic drug experiences, eg, LSD). * van der Kolk and others propose that when a person experiences a traumatic relationship, such as occur in child abuse, a more complex form of trauma develops which is often called complex trauma or sometimes developmental trauma.

Question 32

Types of abuse

Answer 32

physical sexual emotional neglect

Question 33

physical abuse

Answer 33

– hitting, punching, kicking, shaking, beating, burning

Question 34

sexual abuse

Answer 34

penetration, exploitation, exposure to pornographic material

Question 35

Emotional abuse

Answer 35

scapegoating, rejection, persistent hostility, ignoring, isolating, terrorising, verbal abuse, blaming, threatening, discriminating against, ridiculing and belittlement

Question 36

neglect abuse

Answer 36

failure to attend to needs, inadequate supervision, withholding of affection or attention, failure to provide a child with the appropriate support/security

Question 37

The impact of developmental trauma on children

Answer 37

different to other types of trauma (experienced by adults), as the trauma occurs in key critical stages of development and therefore impacts: • Assumptions about self, others, and the world • Relationship to own internal states • Capacity to regulate emotions and cope adaptively with life • The development of the brain • Template for relationships

Question 38

Difficulties experienced by children who experience developmental trauma

Answer 38

``` Academic entration Physiological conduct Emotional and behavioural social ```

Question 39

The effect of developmental trauma, maltreatment and attachment

Answer 39

* A bond that forms between the infant and primary caregiver – provides the working framework for all other relationships * A key conflict for children who have experienced abuse is between the child’s attachment to the caregiver, on the one hand, and the experiences of that caregiver as abusive and uncaring, on the other * This often creates an internal working model of relationships that are impossible to integrate * Significant body of research has found maltreated children have insecure or disorganised attachment styles (for example see Perry, van der Kolk)

Question 40

Emotional dysregulation

Answer 40

* Dysregulation occurs when the child becomes overwhelmed by the emotion. * All types of child abuse impacts on children’s ability to regulate their emotions (Friedrich)

Question 41

hyperarousal

Answer 41

Body goes into a state of alert

Question 42

symptoms of hyperarousal

Answer 42

* Symptoms include sleeping problems, irritability, anxiety, difficulty concentrating * Fight, flight, or freeze - Purpose is instant response, which is probably why other neural processes are often disrupted.

Question 43

neurological results of hyperarousal

Answer 43

Continuous or chronic stress overwhelms the warning function of the amygdala, which normally appraises sensory information for risk.

Question 44

expression of hyperarousal

Answer 44

often expressed later in life as chronic irritability; also over-reacting emotionally

Question 45

Long-term effects of hyperarousal

Answer 45

Can lead to a variety of somatic problems later in life, including heart and blood pressure problems

Question 46

Dissociation

Answer 46

“Dissociation refers to a compartmentalization of experience: elements of the experience are not integrated into a unitary whole, but are stored in memory as isolated fragments and stored as sensory perceptions, affective states or as behavioral reenactments.” (van der Kolk & Fisler, 1995)

Question 47

How do effects of childhood trauma can | persist over time?

Answer 47

• The early developmental impacts of trauma can, and normally do last a life-time. • The literature to support this claim, based on the neurological impacts of violence and neglect, is currently massive. • Adverse Childhood Experiences (ACEs) study – results were devastating: • Over 17000 participants • Looked at exposure to ACE and outcomes in adults • Children didn’t “outgrow” the impacts – pervaded their lives • More adverse experiences in childhood linked to higher rates of mental illness, drug/alcohol use, suicide attempts, financial problems, health problems (smoking, obesity, unintended pregnancy, cancer, emphysema)

Question 48

Long term impacts of childhood trauma

Answer 48

* Can create a disorder which persists * Can create bodily changes which persist * Can alter a pattern of behaviour, which persists * Can change family relations and circumstances, which persist * Sensitivities to stress or coping strategies created, which persist, increasing or decreasing future vulnerability * Changes in child’s self-concept or attitudes persist * Can influence selection of environments later which open or close opportunities

Question 49

Number of diagnoses in children who have experienced trauma

Answer 49

* In children who have experienced developmental trauma – have on average 4-6 diagnoses * Common diagnoses include ADHD, autism, conduct disorder

Question 50

Why is misdiagnosis common?

Answer 50

• In adults, Ross (2000, 2006 (s), 2011 (s)) estimated that approximately 75% of mental health patients of descriptions had some form of interpersonal abuse in their developmental histories. • He said of his own patients at his Dallas clinic that each has attracted about 13 separate diagnoses on average. The chance of a person having 13 discrete mental illnesses he calculated to be approximately one in a trillion. • Large scale studies of in-patients have found as high as 95% have been either physically or sexually abused. • In adults – common diagnoses include personality disorders (particularly Borderline PD), Bi-polar, substance abuse

Question 51

Three ways that treatment can occur for trauma

Answer 51

1. Top-down approaches through talking/connecting with other people (certain therapies) 2. Taking medications that shut down inappropriate threat responses 3. Bottom up approaches – providing the body with experiences that viscerally contradict or collapse the responses that result from trauma

Question 52

Psychotherapy approaches to trauma

Answer 52

* Relationship is key * Interpersonal psychotherapy * Interventions focusing on the brain * Somatosensory interventions * EMDR * Exposure therapy

Question 53

Relationship as a key aspect of trauma treatment

Answer 53

• Relationship is key – particularly in complex trauma as the trauma happens in the context of relationships so healing needs to occur in the context of relationships

Question 54

Interpersonal psychotherapy as a treatment for trauma

Answer 54

relationships, affect regulation, self-concept, personal control, & personal meaning of trauma

Question 55

Interventions focusing on the brain as a treatment for trauma

Answer 55

e.g. Neurosequential Model of Therapeutics

Question 56

Somatosensory interventions as a treatment for trauma

Answer 56

– e.g. sensorimotor therapy

Question 57

exposure therapy as a treatment for trauma

Answer 57

– confronting memories & feared situations – have to be very careful with this, timing is key and may not be appropriate to use

Question 58

What is critical when treating trauma?

Answer 58

Timing and care

Question 59

what is the effect of unresolved trauma on integration abilities?

Answer 59

• Janet (1889) – profound deficits in the ability to integrate experiences occurs in people with unresolved trauma, so may take other forms (e.g. dissociative/somatic)

Question 60

Failure in integration leads to...

Answer 60

“compartmentalization of experience: elements of a trauma are not integrated into a unitary whole or an integrated sense of self” (van der Kolk et al., 1996)

Question 61

Comorbidity and treatment of dissociative and somatic disorders

Answer 61

lots of people have both dissociative and somatoform disorders. both are understood and treated in similar ways

Question 62

dissociation

Answer 62

Traumatic stress disorders, dissociative disorders, and SSDs look different, but share an important similarity: dissociation – the disruption of the normally integrated mental processes.

Question 63

Depersonalization/derealization

Answer 63

feeling of being detached from the world around us or oneself. *”As if” feelings – not delusional beliefs e.g. I feel as if my body was not connected to my brain

Question 64

core features of dissociative disorders

Answer 64

persistent, maladaptive disruption in the integration of memory, consciousness, identity, emotion, perception, body representation, motor control and behaviour.

Question 65

Specific diagnoses of dissociative disorders

Answer 65

* Dissociative Amnesia * Depersonalization Disorder * Dissociative Identity Disorder

Question 66

Dissociative identity disorder

Answer 66

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensorymotor functioning. These signs and symptoms may be observed by others or reported by the individual B. Gaps in the recall of important personal information that are inconsistent with ordinary forgetting C. Distress or impairment D. Not explained by cultural factors or religion E. Exclude substance, medical condition

Question 67

primary and alternate identites in DID

Answer 67

* The “primary” identity may be relatively passive, dependent, or report feeling guilty or depressed * Alternates usually contrast to primary * Differ in age, gender, skills, mannerisms * Alternates can emerge in response to specific situations/emotions * 10 or fewer alternates most common

Question 68

Associated features of dissociative identity disorder

Answer 68

* Confusion and memory gaps * Self harm or suicidal behaviour * Common comorbid diagnoses: Mood, substance, sexual, eating, sleep. * More common in women (why?)

Question 69

When can dissociative identity disorder present?

Answer 69

the full disorder can first present at any age

Question 70

DID controversies

Answer 70

1. Most cases of dissociative disorders are diagnosed by a handful of “ardent” clinicians; 2. they rarely occur outside of USA & Canada 3. The frequency of dissociative disorders (& DID in particular increased) rapidly after release of the very popular book & movie Sybil. (cf. Sar, 2011 - under-diagnosed) 4. The number of personalities claimed to exist has grown rapidly [what could explain this]? 5. Symptoms of DDs are more extreme than those found in measures of dissociation

Question 71

Etiology of DID

Answer 71

Generally accepted that childhood trauma plays a key role in development of DID *90% of people with DID in United States, Canada, and Europe reported history of child abuse/neglect [but the data are often only retrospective, ?verifiable, and as with PTSD, most people who experience trauma do not develop a DD, including DID]. • The possibility of a “social” cause or contribution? - Iatrogenesis

Question 72

Treatment and management of DID

Answer 72

poorly evaluated at this time Possibly: integration via uncovering the trauma about which the person might not even be aware? or aiming for acceptance of & “co-operation” among the alters (ISSTD, 2011).

Question 73

Essential features of somatic symptom disorders

Answer 73

(for SSDs, except Factitious) –Complaints about physical symptoms in the absence of a medical cause that are psychologically distressing / impairing –The complaint is experienced as “bodily” and real [like an ordinary (medically explained) symptom]. –Often associated with numerous, evolving, and nonspecific complaints such as chronic pain, upset stomach, dizziness.

Question 74

Categories of Somatic symptom disorder

Answer 74

* Somatic symptom disorder * Conversion disorder * Illness anxiety disorder (Hypochondriasis) * Psychological factors affecting other medical conditions * Factitious Disorder

Question 75

Conversion Disorder

Answer 75

“People with this disorder display physical symptoms that affect voluntary motor or sensory functioning, but the symptoms are inconsistent with known medical diseases…..In short, the individuals experience neurological like symptoms – blindness, paralysis, or loss of feeling - that have no neurological basis” Serious neurological symptoms occur and affect behaviour – here blindness in an individual with normal sight. CD is rare and thought to occur at times of acute stress.

Question 76

Conversion Disorder criteria

Answer 76

A. One or more symptoms of altered voluntary motor or sensory function. B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. C. Not due to another medical or mental disorder. D. Distressing/Impairment

Question 77

Symptoms of conversion disorder

Answer 77

``` “Psuedo” or “functional” neurological features –Impaired coordination –Paralysis -Seizures -Tics –Localised weakness –Difficulty swallowing –Loss of sense of touch / Speech –Numbness –Double vision/blindness –Deafness ```

Question 78

Prevalence of SSD

Answer 78

Actual prevalence unknown, but typically considered | •More common among women (10 times) and in people w lower SES

Question 79

age of onset for SSD

Answer 79

Adolescence or early adultood

Question 80

Comorbidities of SSD

Answer 80

Depression, anxiety, antisocial personality disorder

Question 81

Theorised causes of SSD

Answer 81

Etiology is under-researched. SSDs are diagnosed by exclusion, which does not assist in establishing etiology; associated with stressors (also a historical link to WW1).

Question 82

Possible biological causes of SSD

Answer 82

A missed organic explanation for the Sx

Question 83

Possible physiological causes of SSD

Answer 83

– Underlying trauma / identity issues – Difficulty with emotional /psychological expression – Primary and secondary gain – Cognitive tendencies: amplification, alexithymia

Question 84

Psychological treatments of SSD

Answer 84

– Interpersonal psychotherapy – If symptoms incl. pain, operant (behavioural) approaches might be tried – Changing the cognitive overlay/interpretation/meaning of symptoms

Question 85

interpersonal psychotherapy as treatment for SSD

Answer 85

addressing underlying trauma/psychological conflict/identity reintegration – historically, “cathartic” therapies for CD –promoting emotional expression/recognition

Question 86

operant (behavioural) treatments for SSD

Answer 86

rewarding successful coping and adaptation

Question 87

Changing the cognitive overlay/interpretation/meaning of symptoms as treatment for SSD

Answer 87

cognitive behavioural therapy; cognitive restructuring