Trauma Related & Dissociative Disorders

Final Exam

Trauma/Traumatic Stress

Event of extreme distress that invokes remarkable danger and/or horror

Any event that involves actual or threatened death, serious injury, or sexual violence

DSM-5 Dissociative Disorders

Persistent, maladaptive or distressing disruptions in the integration of perception, memory, and identity

Ways trauma may be experienced

• Direct exposure to trauma

• Witnessing it occur to someone else

• Learning it occurred to someone else

• Repeated/extreme exposure to details of trauma

Ex, Military combat, rape, bombings, war, massacre, disasters, crashes, accidents, death

PTSD

Severe negative aftereffects longer than a month after a trauma

Symptoms of PTSD/ASD

Traumatic Stress

Re-experiencing

Avoidance

Negative mood/thoughts

Arousal/Reactivity

Re-Experiencing

Recurrent experiences reminiscent of the trauma

1. Recurrent, intrusive memories of the event

2. Repeated distressing dreams

3. Flashbacks

Flashbacks

• Suddenly replaying the trauma in images or thoughts

• Re-experiencng the trauma as though it were actually happening

• Can occur in a DISSOCIATIVE STATE:

  • Loss of awareness of the true, surrounding reality

Avoidance of internal & external experiences

Persistent avoidance of stimuli associated with the trauma

1. Avoidance of distressing memories, thoughts, or feelings related to teh event

2. Avoidance of external reminders that arouse distressing memories, thoughts, or feelings related to the event

• People, places, conversations, activities, objects, etc

Negative mood symptoms of PTSD

Persistent negative emotions like fear, horror, sadness, anger, shame

• Persistent NEGATIVE beliefs about oneself, others, or the world

• Persistent, distorted COGNITIONS about the cause of the trauma

• Diminished interest or pleasure in activities (ANHEDONIA)

• DETACHMENT from others

• General numbing of responsiveness: EMOTIONAL ANESTHESIA

Emotional anesthesia

General numbing of responsiveness

Arousal/Reactivity symptoms of PTSD

Unprovoked irritable behavior and angry outbursts

• Usually against others

• Hypervigilance

• Exaggerated startle response

• Reckless or self-destructive behavior

• Problems with concentration

• Sleep disturbance

Startle response

Exaggerated….

PTSD Diagnosis

1. Exposure to actual or threatened death, serious injury, or sexual violence by:

   • Directly experiencing it, witnessing it, learning it occured to close others, or repeated/extreme exposure to details of trauma

2. Intrusive re-experiencing (1)

3. Avoidance (1)

4. Increased Arousal or Reactivity (2)

5. Negative mood or thoughts (2)

6. Lasts for longer than one month

7. Distress or impairment

Acute Stress Disorder Diagnosis

• Must have 9 symptoms from any of 5 categories:

  1. Intrusive re-experiencing

  2. Avoidance

  3. Increased arousal or activity

  4. Negative mood

  5. Dissociative symptoms

Interpersonal symptoms of PTSD

• PTSD is linked to interpersonal, marital, & sexual dysfunction

  • Social withdrawal (UP)

  • Interpersonal conflict/marital conflict (UP)

  • Diminished sexual drive and erectile dysfunction

    • Avoidance of sex due to aversion of arousal is common

Causes/Risk factors of PTSD

Victims more likely to develop PTSD when trauma is:

• More intense

• Life-threatening

• Involves greater exposure to event

Sexual violence

• Most victims of rape show PTSD and depression symptoms, commonly including self-blame

Avoidance

• Increases intrusive symptoms and prevents emotional processing and disconfirmation of trauma beliefs

Cognitive factors

• Maladaptive, extreme beliefs formed due to the trauma

Factors of trauma that increase risk of developing PTSD

Avoidance of trauma-related stimuli, thoughts, & feelings is a major factor determining who develops PTSD and who does not

• Avoidance of experiences associated with the client’s trauma predicts and mediates/explains the development of PTSD later

Sexual violence statistics

• 10-20.4% of women have been raped at least once in their lifetime

• 22% have been sexually assaulted in adulthood

• Those victimized in youth are more likely to be assaulted as adults

  • Teenage victims are 4.4x more likely to be assaulted 1st year of college

• Most victims show PTSD and depressions symptoms, commonly including self-blame

  • Symptoms increase when victim-blaming behaviors are encountered

  • 4/5 acquaintance rapes are not reported to authorities

Effects of avoidance in PTSD

• Post-traumatic symptoms are common immediately following a trauma

  • But most who experience a trauma do not develop PTSD

• Natural recovery by EMOTIONAL PROCESSING

  • Activating of trauma memory by repeated engagement with trauma-related stimuli, thoughts/feelings

• Using avoidance to cope with trauma predicts later major increases in intrusive symptoms

• Avoidance of trauma-related stimuli, thoughts, & feelings is a major factor determining who develops PTSD and who does not

• Avoidance PREVENTS:

  • Emotional processing

  • Disconfirmation of trauma beliefs

• Avoidance of experiences associated with the client’s trauma predicts and mediates/explains the development of PTSD later

Faulty memory storage during trauma

Fragmented, incomplete, or blocked memories, dissociation, and emotional flashbacks, rather than clear narratives, causing memory gaps and difficulty integrating the experience, with memory issues often improving with therapy

Cognitive causes of PTSD

• Maladaptive, extreme beliefs formed due to the trauma

  • “The world is unsafe; I’m incompetent; I’m at fault; People are vicious”

• Trauma memories are encoded in a fragmented manner

  • High arousal interferes with full, coherent memory storage

  • This poor memory leads to poorer processing & exposure later

• Attentional biases to threat

• Difficulty recalling specific positive memories

Protective factors of PTSD

• Social support after trauma

  • They have someone to tell about their trauma

• Coping with trauma can be aided with:

  • Preparedness:

    • Knowledge, correct expectations, and sense of mastery concerning the type of traumatic event

      • Ex, Activists develop PTSD less than non-activists after torture

  • Purpose in life

  • Calmness and control during trauma

  • Sense of control in general

• Emotional Processing

  • Not avoiding their trauma

• Meaning Making — Finding some value or reason for having endured trauma

  • Often involves deciding on how to serve others because of it

    • Ex, someone who loses a friend due to texting and driving. That person dedicates their life to advocating for change (Pushing for more law enforcement to prevent texting while driving, having a bumper sticker created, etc)

    • Ex, Me-Too Movement

• List-Traumatic Growth

  • Positive changes following trauma

Preparedness

Knowledge, correct expectations, and sense of mastery concerning the type of traumatic event

Adjustment disorder

The presense of emotional and behavioral symptoms in response to an identifiable stressor(s)

• Occuring within 3 months of the stressor(s)

• Distress is out of proportion with expected reactions to the stressor

• Clinically signiificant

• Once stressor stops, symptoms must subside within 6 months

Resilience

The ability to bounce back from adversity, trauma, or significant stress by going through challenges (Protective factors)

Emotional processing

Not avoiding trauma

Meaning making

Finding some value or reason for having endured trauma

• Often involves deciding on how to serve others because of it

  • Ex, Me too movement, dedicating life to advocating for change after devastating event

Posttraumatic growth

Positive changes following trauma

Prevention/treatments for PTSD

Cognitive Behavioral Therapy

Prolonged Exposure — Clients engage with traumatic memories and stimuli, reliving the trauma until they habituate

• Likely the most efficacious treatment (for all trauma types)

Imagery Rehearsal Therapy — Relive nightmares while awake, but rewrite the narrative as desired

Eye-Movement Desensitization and Reprocessing (EMDR) — Rapid back-and-forth eye movement while reliving images of trauma

• Works because of exposure — no special effect of eye movement

Prolonged exposure

Clients engage with traumatic memories and stimuli, reliving the trauma until they habituate

• Likely the most efficacious treatment (for all trauma types)

Imagery rehearsal therapy

Relive nightmares while awake, but rewrite the narrative as desired

Eye movement desensitization and reprocessing (EMDR)

Rapid back-and-forth eye movement while reliving images of trauma

• Works because of exposure, no special effect of eye movement

Controversy and evidence re: EMDR

Unclear emchanism. Questons if it’s more than just exposure therapy, and debates over the sufficiency of its training and research quality

Failing to prevent an outcome is not a cause of the outcome

Crucial PTSD mental health point. Don’t let clients blame themselves

Dissociation

Disruption or discontinuity in the integration of consciousness, memory, identity, emotion, body representation, motor control, and behavior

• Impaired awareness of:

  1. Perception

  2. Memory

  3. Awareness

• Can disrupt any type of psychological function

  • Access to certain information

  • Control of attention and behavior

• All dissociative symptoms are on a continuum of severity

  • Normal “lapses” in awareness ——> Repeated, but infrequent, dissociation ——> Constant, intense dissociation

Depersonalization

Characterized by feelings of being detached from oneself

• Feeling detached from one’s own body and mind

  • Sense of being an “outside observer”

  • Separated from what’s inside of you

• Detached from surrounding — feeling they are “unreal”

  • Sense of being “in a fog”

  • Separated from what’s OUTSIDE you

• Inability to distinguish reality

• NOT DUE to medical issue, substances, or other disorder

Derealization

Characterized by feelings of being detached from the world

• Derealization commonly includes visual or auditory distortions

  • Blurriness, widened/narrowed visual field, muted sounds, etc

• NOT DUE to medical issue, substances, or other disorder

Dissociative amnesia

Characterized by inability to recall autobiographical information

• Often lose time or have gaps in their memory

• Specifier

  • Dissociative Fugue

Dissociative fugue

Sudden travel or bewildered wandering

• Inability to recall one’s past

Dissociative Identity Disorder

Sense of self “fragments” into multiple sense of self, or even identities

• Called alters

• At its extreme, multiple persons appear to co-exist in one individual

• Includes dissociative amneisa and depersonalization/derealization as well

Symptoms serving FUNCTIONS

Psychological symptoms often help or serve sufferers

• Tolerates emotionally overwhelming experiences

• Prevents stress

Symptoms resulting from FLAWS

Result from a deficiency or problem

• Persists when unnecessary

• Prevents growth

• Not wanting to listen or avoiding hard situations

Trauma model of dissociation

• FUNCTION of dissociation:

  • To TOLERATE emotionally overwhelming experiences

• FLAW: It persts when unnecessary

• Dissociation during traumatic events is common

  • Occurs during 66% of traumas

• Most of those with dissociative disorderes have experience trauma

  • Meta-analysis of 39 controlled studies

Evidence for trauma model (including Briere 2006 and Khalil 2013 studies)

• Dissociation and distress during trauma + Lower emotion regulation skill = Development of dissociative disorders

• Dissociation and distress during trauma + Higher emotion regulation skill = No development of dissociative disorders

Recovered memory debate and why it matters

• People may claim a memory returned after it was kept out of awareness due to trauma

  • Dissociation is blamed for “blocking” the memory

• Yet these memories are false

  • They may result from a therapist’s suggestion that they exist

• Memory is re-writable and very often innacurate

• THere is little direct evidence for inability to access FULL memories that were rpeviously stored

  • Therapists can influence clients to believe that something happened when it actually didn’t

Fantasy model of dissociation

• Proposes that dissociation is causally unrelated to trauma

  • Dissociation is related to tendencies to engage in fantasy making, being suggestible, & thought distortion (found in correlational studies)

  • Thus, dissociators may be prone to “make up” false trauma memories, believe therapist suggestiong, and suggest behavior

Evidence related to fantasy model

• Highly fantasy-prone persons are diagnosed with dissociative disorders more often than low-medium fantasy-prone persons

  • Fantasy-proneness is positively associate with dissociation

• Dissociation is a FLAW that becomes worse when therapists suggest wrong causes for the flaw

  • Comes to believe what the therapist is saying because of the overactive suggestibility

Alternate explanations of dissociative disorders/dissociative amnesia (only some possibilities)

1. Disruptive distress leads the memory to never be stored in the first place

2. Avoiding thinking about the memory leads to forgetting

3. Like most childhood memories, it is simply forgotten (or unaccessed until appropiately cued)

4. Dissociation has a social function: Culturally-allowed expressions of unacceptable feelings

Iatogenic effects

Harm caused by therapy; Creating a disorder by its treatment

• Suggestions that a client has alters amy lead them to form and act out alters

Alters

Sense of self “fragments” into multiple sense of self, or even identities

Controversy/debate over existence of dissociative identity disorder and evidence for and against its existence

• Scholars disagree very strongly over DID’s existence

• There are good reasons to disbeliee many DID cases

  1. The average number of personalities in a DID case has skyrocketed over time

  2. DID is rarely diagnosed outside US/Canada

  3. Most DID diagnoses have been made by the same people consistently in centers

  4. The greatest predictor of improvement for DID is stopping therapy