Stress + Dissociative Disorders

when does acute stress disorder occur

occurs during or immediately after trauma

what can acute stress disorder develop into

PTSD

what can cause acute stress disorder

• witnessing/experiencing a violent or gruesome death of or by an intimate

• repeated exposure to averse details of an event

  • ex. first responder who collect body parts, police repeatedly exposed to details of child abuse

what types of symptoms can occur with acute stress disorder (5)

 Intrusive symptoms

 Dissociative symptoms

 Avoidance symptoms

 Arousal symptoms

 Negative Mood

intrusive symptoms (re-experiencing)

• recurrent, involuntary, intrusive + distressing memories, dream or flashbacks related to the event

• intense psychological/physiologic distress when reminded of the event

  • similar location, similar sounds heard during the event

dissociative symptoms

• more common in ASD than in PTSD

• subjective sense of numbing or detachment, reduced awareness of surroundings, derealization, depersonalization, or dissociative amnesia

avoidance symptoms

avoiding distressing memories, thoughts, feelings or external reminders (people, places, conversations, activities, objects, situations) associated with the event

arousal symptoms

 Sleep disturbance

 Irritability or angry outbursts

 Hypervigilance

 Difficulty concentrating

 Exaggerated startle response

negative mood

• persistent inability to experience positive emotions

  • happiness, satisfaction, loving feelings

how is ASD treated (2)

• psychotherapy

• pharmacotherapy

ASD psychotherapy

• CBT

  • trauma-focused (4 components)

• EMDR

pharmacotherapy

minimal evidence supporting medications to treat ASD

PTSD definition

• develops after seeing/being involved in a traumatic experience

• symptoms occur for longer than 1 month

PTSD results in : (6)

 Feelings of intense fear, helplessness or horror

 Persistent re-experience of trauma

 Consistent and persistent avoidance of stimuli associated with trauma

 Persistent heightened feelings of arousal

 Impairment in functioning

 Symptoms influenced by developmental stage

risk factors that increase the likelihood of developing PTSD

 Being exposed to previous traumatic experiences, particularly during childhood

 Getting hurt or seeing people hurt or killed

 Feeling horror, helplessness, or extreme fear

 Having little or no social support after the event

 Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home

 Having a personal or family history of mental illness or substance use

comorbidity with PTSD

 Major depressive disorder

 Anxiety disorders

 Sleep disorders

 Dissociative disorders

 Substance use disorders

PTSD length

can begin 1 month after exposure, but can have delay of motnhs or years

specific types of trauma exposure (4)

 Directly experiencing a traumatic event

 Witnessing a traumatic event that happened to someone else

 Learning about a traumatic event happening to a close friend or family member (cases of death must be violent or unexpected)

 Does not include exposure to electronic media like television, movies or photographs

DSM criteria for PTSD

• Individuals must have been exposed directly or indirectly to a traumatic event, and

• Must have at least:

 1 or more intrusion/re-experiencing symptoms

 1 or more avoidance symptoms

 2 or more reactivity and arousal symptoms, and

 2 or more alterations in mood

symptoms of PTSD in children and adolescents

 Reliving the event repeatedly in thought or in play.

 Becoming very upset when something causes memories of the event.

 Hypervigilance or constantly looking for possible threats, being easily startled.

 Denying that the event happened or feeling numb.

 Lack of positive emotions.

 Acting helpless, hopeless or withdrawn.

 Nightmares and sleep problems.

 Irritability, aggressive or self-destructive behaviors.

 Problems concentrating.

 Feelings of detachment or estrangement from others including avoiding places or people associated with the event

 Diminished interest or participation in significant activities.

 Somatic symptoms such as headaches, stomachaches, or pain; memory problems, etc

2 treatments of PTSD

• trauma-focused psychotherapy

• pharmacotherapy

what is the primary treatment for PTSD

trauma-focused psychotherapy

trauma-focused psychotherapy

• Exposure (PE)

• Cognitive Processing Therapy (CPT)

• Eye Movement Desensitization and Reprocessing (EMDR)

pharmacotherapy for PTSD

 SSRI: sertraline, paroxetine, fluoxetine (off-label)

 SNRI: venlafaxine (off-label)

 MAOI: phenelzine (off-label)

PTSD tx for children + adolescents

• Psychotherapy:

  • CBT  first line

  • EMDR first line

  • Play Therapy

• Pharmacotherapy:

  • Currently there are no FDA approve medications for children and adolescents.

  • SSRIs (off-label) may address specific symptoms of PTSD, when they significantly interfere with their daily functioning.

EMDR

eye movement desensitization and reprocessing therapy

first line treatment for traumatized children

EMDR

how does EMDR work?

• Individuals are encouraged to think about the traumatic event while also focusing on other stimulation, such as eye movements, audio tones, or tapping

• may work through neurological and physiological changes that help to process and integrate traumatic memories

what is trauma informed care?

• Involves recognizing and responding to the effects of all types of trauma

• recognizing the signs and symptoms of trauma

• actively avoiding re-traumatization

Inpatient Management of PTSD (4)

 Use of trauma-informed care conceptual model

 Provider recognition of patients who may have PTSD

 Collaboration

 Individualizing care

Inpatient issues that may affect PTSD

• sleep hygiene

• pain

• anxiety + hunger

how can you tell when treatment is effective in the patient?

 can recognize symptoms as related to the trauma.

 able to use newly learned strategies to manage anxiety.

 experiences no flashbacks or intrusive thoughts

 able to sleep adequately without nightmares.

 can assume usual roles and maintains satisfying interpersonal relationships.

attachment disorders

 Reactive Attachment Disorder

 Disinhibited Social Engagement Disorder

adjustment disorders timeline

• emotional or behavioral reaction within 3 months of exposure to stressor

  • ex. loss of death or loved one

• reaction is out of proportion to stressor severity

• symptoms end by 6 months

adjustment disorder symptoms

• anxiety, depression, regressive behaviors in children

• fearful or acting out behavior

adjustment disorder therapy

 Active listening, therapeutic communication skills

 Assist in increasing coping skills

intervention stages

1: provide safety and stabilization

2: reduce arousal and regulate emotion through symptom reduction

reactive attachment disorder

• difficulty forming healthy emotional attachments with caregivers

  • due to early childhood trauma or neglect

  • can be caused by abuse, inconsistent caregiving, frequent changes in primary caregivers, institutional care with limited emotional responsiveness

when does reactive attachment disorder develop

• infancy or early childhood

• can affect a child’s social, emotional, cognitive development, potentially leading to difficulties in school, relationships, and overall well-being

what is reactive attachment disorder characterized by

disturbed and developmentally inappropriate social relatedness

reactive attachment disorder behaviors

 Unexplained withdrawal, fear, sadness or irritability

 Sad and listless appearance

 Not seeking comfort or showing no response when comfort is given

 Failure to smile

 Watching others closely but not engaging in social interaction

 Failing to ask for support or assistance

 Failure to reach out when picked up

 No interest in playing peekaboo or other interactive games

disinhibited social engagement disorder (DSED) chracteristics

 Demonstrate no normal fear of adult strangers or shyness when meeting people for the first time.

 Seem unfazed in response to separation from a primary caregiver.

 Tend to be overly friendly and are usually willing, or even eager, to go with someone they do not know.

 Younger children may allow unfamiliar people to pick them up, feed them, or play with them.

what is DSED

strongly linked to early childhood experiences of neglect or inconsistent caregiving, such as growing up in foster care or institutional settings

what is the primary goal of tx for RAD and DSED

strengthen relationship between child and caregiver

• without tx child may have lifelong consequences, including lack of trust or not feeling secure in friendships and relationships

RAD and DSED tx

• educate caregivers about the condition

• ensure a safe and stable living situation after discharge

how to create stable and nurturing environment

 Experiences positive interactions with caregivers and staff.

 Experiences attachment through the five senses.

how to ensure a safe and stable living situation after discharge

 Encouraging child's development by being nurturing, responsive & caring

 Providing consistent caregivers to encourage stable attachment.

 Providing a positive, stimulating and interactive environment

 Addressing the child's medical, safety and housing needs.

 Increasing touch, talk and socialization:

 Hold, hug, touch, feed, and talk to the child; use story-telling.

 Encourage meals with other children and familial caregivers.

dissociation

involve a disruption in the consciousness with a significant impairment in memory, identity or perceptions of self

dissociative disorders

• disturbances in a normally well-integrated continuum of consciousness, memory, identity, and perception

• Dissociation

• Intact reality testing- is not delusional and not hallucinating.

• Includes amnesiac states

dissociation

unconscious defense mechanism to protect an individual against overwhelming anxiety

types of dissociative disorders

 Depersonalization disorder

 Derealization disorder

 Dissociative amnesia

 Dissociative fugue

 Dissociative identity

depersonalization disorder

 Person experiences a distorted perception of self, while reality resting remains intact.

 Feels in a dream-like state

derealization disorder

Person experiences a distorted perception of surroundings while reality testing remains intact

dissociative amnesia

 Psychologically induced memory loss and inability to recall important personal information after severe stressor

 Perplexity, disorientation & purposeless wandering

dissociative fugue

Sudden, unexpected travel from a customary locale, and the inability to recall one’s identity after a traumatic event

dissociative identity disorder (DID)

 Formerly known as multiple personality disorder, which is the presence of two or more personality states that control behavior.

 Alternate personality (alter) or subpersonality

alternate personality (alter) or subpersonality

Has its own pattern of perceiving, affect, cognition, behavior, and memories

what exposes a person to DID

sever sexual, physical, and or psychologic trauma in childhood predisposes an individual to DID

depersonalization/derealization disorder tx

• often short-lived and go away on their own without treatment

• some treatment modalities have been used with success, including self-hypnosis, CBT and repetitive transcranial magnetic stimulation (rTMS)

depersonalization/derealization disorder pharmacotherapy

no meds have been proven to effectively tx but can be used to treat comorbid disorders and symptoms