PSY388 Lecture 4: Emotional Disorders 3: Trauma- and Stressor-Related Disorders; Somatic Symptom and Dissociative Disorders

Trauma- & Stressor-Related Disorders

Posttraumatic Stress Disorder (PTSD)

Acute Stress Disorder

Adjustment Disorders

The prevalence of PTSD in Primary Care

PTSD in this setting is common (regardless of the type of population) with the medican prevalence (12.5%) approximating that of depression.

The prevalence of psychological disorders in individuals with and without posttraumatic stress disorder

DSM-5-TR Posttraumatic Stress Disorder (PTSD) - Criterion A

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

LEC-5 (NCPTSD, 2013)

Criterion A & PTSD Recovery

DSM-5-TR PTSD

• Intrusion “reexperiencing” sx (e.g., recurring intrusive memories, flashbacks, disturbing dreams/nightmares)

• Avoidance

• Negative alterations in cognition/mood (e.g., shame/guilt/blame, impaired memory, depression, anhedonia

• Altered arousal/reactivity (e.g., hypervigilance, exaggerated startle, aggression, irritability, impaired attention/concentration, sleep disturbance)

• Different criteria for children under 6 years old

ICD-11 PTSD

• Re-experiencing symptoms (e.g., recurring intrusive memories, flashbacks, disturbing dreams/nightmares)

• Deliberate avoidance

• Persistent perceptions of heightened current threat (e.g., hypervigilance, exaggerated startle, aggression, irritability, impaired attention/concentration, sleep disturbance)

• Negative alterations in cognition/mood (e.g., shame/guilt/blame, depression, anhedonia) - Additional clinical features

PTSD

PTSD: EvidenceBased Treatments

• Little evidence for pharmacotherapy alone for PTSD

• High dropout of all treatments for PTSD

• Use of MDMA for PTSD, only after use of other treatments haven’t worked due to expenses

Meditation and Yoga for PTSD treatment

• Both patients & providers ask for more PTSD treatment options

• Meditation & yoga allow for a variety of treatment options & address several domains of PTSD.

• Meditation & yoga-based approaches yielded small to medium effects on PTSD symptom reduction.

• Complementary interventions increase patient choice & offer a second-line treatment option.

• Efforts to move toward integrative approaches for PTSD warrant further study.

Dissociative Disorders

Dissociative Identity Disorder (DID)

Dissociative Amnesia

Depersonalization/Derealization Dx

DSM-5 Dissociative Disorders

• Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour

• “Positive” symptoms: intrusions and loss of continuity (e.g., fragmented identity, depersonalisation, derealisation)

• “Negative” symptoms: inability to control function or access info (e.g., amnesia)

Dissociative Identity Disorder (DID)

• Two or more distinct identity or personality states

• Up to 90% report hx of trauma, abuse, neglect

• High suicide risk (~70%)

Dissociative Amnesia

• Loss of memory for personal info

• “Amnesia for their amnesia”

Depersonalisation/Derealisation Disorder

• Changes to sense of self (e.g., an outside observer to oneself, or detached)

• Changes to sense of world (e.g., surroundings suddenly seem foreign, lacking depth)

Dissociative identity as a continuum from healthy mind to psychiatric disorders: Epistemological and neurophenomenological implications approached through hypnosis

During hypnosis the subjects underwent spontaneous non-intrusive experiences of other selves which were not recalled after the end of the session, due to posthypnotic amnesia. The fMRI showed a significant decrease of connectivity in the DMN especially between the posterior cingulate cortex and the medial prefrontal cortex.

Dissociation in Psychiatric disorders

Symptoms of dissociation are present in a variety of mental disorders and have been connected to higher burden of illness and poorer treatment response, and not only in disorders with high levels of dissociation

Epidemiology of depersonalisation and deralisation

transient symptoms of depersonalisation/derealisation in the general population are common, with a lifetime prevalence rate of between 26 and 74% and between 31 and 66% at the time of a traumatic event

Treatment of Dissociative Disorders

Three-phased approach:

1. Safety, stabilisation, symptom reduction

2. Cognitive reappraisal and integration of traumatic memories

3. Integration and rehabilitation of different identities

Other potential approaches (typically, trauma-focused):

• DBT

• Transdiagnostic CBT

• Schema Therapy

• Imagery Rescripting

• Interpersonal Therapy

• ?Hypnosis

• ?rTMS

• ?Medicatio

Somatic Symptom & Related Disorders

Somatic Symptom Disorder

Illness Anxiety Disorder

Functional Neurological Symptom Disorder (Conversion Disorder)

Factitious Disorder

Chronic pain, psychipathology & DSM-5 Somatic symptom disorder

Historically, pain without an apparent anatomical or neurophysiological origin was labelled as psychopathological. This approach is damaging to the patient and provider alike…many medically unexplained pains are now understood to involve an interplay between peripheral and central neurophysiological mechanisms that have gone awry. The new DSM-5 somatic symptom disorder overpsychologizes people with chronic pain; it has low sensitivity and specificity, and it contributes to misdiagnosis, as well as unnecessary stigma [emphasis added]

Comorbidity(a) of 12-month mental disorders and physical conditions, by sex, 2020–2022

Somatic Symptom Disorder

• Experience distressing or debilitating somatic symptoms

• Excessive thoughts, feelings, behaviours

• Somatic sx may be explained OR unexplained by medical condition

• Most common = w/ predominant pain, persistent

Illness Anxiety Disorder

• Preoccupation with & worry/anxiety about getting a serious illness

• Excessive health “checking”, reassurance seeking, help seeking or avoidance

• Somatic sx nonexistent or only mild

Functional Neurological Symptom Disorder (Conversion)

• Unexplained disturbance in motor or sensory functioning (e.g., loss of function)

• Clinical review finds incompatibility between symptom and recognised neurological/medical condition

Factitious Disorder (by Proxy)

• Deliberate fabrication of psychological or medical symptoms

• No obvious external reward (other than attention/comfort)

Somatic Symptom Disorder w/ predominant pain “CBT for Chronic Pain”

Treatment of Somatic Symptom Dx “CBT for Chronic Pain”

Individual and group-based CBT:

• Psychoeducation

• Cognitive reappraisal

• Behavioural experiments

• Paced activities

• Graded exposure

• Response prevention (reassurance-seeking, avoidance)

Medical:

• ONE primary physician

• Assessment

• Non-prescription analgesics