PSYC 2285 - Chapter 7 Trauma and Dissociation

Post-Traumatic Stress Disorder

Enduring, distressing emotional disorder that follows exposure to a severe helpless or fear-inducing threat. The victim re-experiences the trauma, avoids stimuli associated with it, and develops a numbing of responsiveness and an increased vigilance and arousal. Can result from actual or perceived threats to life, serious injury or sexual violence. Strong and independent predictor of suicidal behaviour. 

PTSD Symptoms:

• Re-experiencing the event through memories and nightmares

• Avoiding anything that reminds them of the trauma

• Feeling numb or having a restricted range of emotions which may cause issues to interpersonal relationships

• Unable to remember certain aspects of the event

• Avoid experiencing certain emotions or sensations (Similar to PD)

• Changes in the way they think about themselves, others and the world, feeling like they are not safe or others cannot be trusted

• Typically are chronically over aroused, easily startled and quick to anger (Hyper vigilance)

• May engage in reckless or self-destructive behaviour

• Dissociative subtype

Acute Stress Disorder

Severe reaction immediately following a terrifying event, often including amnesia about the event, emotional numbing and derealization. Many survivors later develop post-traumatic stress disorder. Symptoms have to have appeared within 30 days of the traumatic event to be acute. People can move out of this state after 30 days to no longer have PTSD related disorders.

Delayed-Onset PTSD

Individuals show few if any symptoms immediately or for months after a trauma, but at least six months later and perhaps years afterward, develop full-blown PTSD

Levels of Trauma Exposure

• Direct experience (Most likely to cause severe PTSD)

• Witnessed 

• Hearing something happening through another person 

• Repeated exposure through a job (like EMS) 

Exposure more personally and direct seems to result in more cases of the disorder

Biological Influences in PTSD

• The greater the vulnerability the more likely to develop it

• If certain characteristics run in the family - Ex. History of anxiety suggests generalized biological vulnerability for PTSD

• Genetic factors may also contribute to the risk of being exposed to certain kinds of traumas (possibly through inherited personality characteristics affecting the environment they are in)

• Genetic factors predispose individuals to be easily stressed and anxious leading to making it more likely a traumatic experience with result in PTSD

• Elevated or restricted corticotropin-releasing factor (CRF) which indicates heightened activity in the HPA axis

• Chronic arousal associated with HPA axis activity and some other symptoms of PTSD may be directly related to changes in brain function and structure and in turn influence treatment response

• Hippocampus plays an important role in regulating the HPA axis and in learning and memory - damage could then create persistent and chronic arousal and disruptions in learning and memory

Biological Personal Characteristics

• Increase the likelihood for developing PTSD

• Experiencing more emotional reactivity may result in higher risk for developing PTSD symptoms

Generalized Psychological Vulnerability

• Family instability may instill a sense that the world is uncontrollable, potentially dangerous place

• Anxiety sensitivity - Greater levels of anxiety sensitivity at pretreatment baseline predicted greater severity of PTSD

Social and Cultural Factors

• Strong and supportive group of people around a person makes it less likely they will develop PTSD after a trauma

• Lack of social support may relate to higher reports of PTSD

• Positive coping strategies involving active problem solving seems to be protective

• Support from loved ones reduces cortisol secretion and HPA axis activities in children during stress

Imaginal Exposure

Content of the trauma and the emotions associated with it are worked through systematically

Prolonged Exposure therapy

Strategy to achieve imaginal exposure, working with the survivor to develop a narrative of the traumatic experience and to expose the patients for an extended period of time to the narrative that is then reviewed extensively. Rewriting the emotions tied to a traumatic event.

CBT for PTSD used to:

To correct negative assumptions about the trauma such as blaming oneself in some way, feeling guilty or both is often part of the treatment 

CBT Treatment for PTSD

Uses a constructivist-narrative approach for treating individuals who have been traumatized. Therapist assists clients in reconstructing their “story” about the traumatic event, changing the meaning that the clients have attached to the traumatic event and helping them develop adaptive coping strategies and a sense of survivorship. 

Eye-Movement Desensitization and Reprocessing

While in therapy and thinking about their traumatic experiences, clients are asked to follow the therapist’s moving fingers with their eyes, all the while keeping the image of the trauma in mind. Said to facilitate rapid reprocessing of the traumatic event.

Drug Therapy for PTSD

• Can be effective for symptoms of PTSD

• Drugs like SSRIs that are effective for anxiety disorders in general are helpful

Accelerated Resolution Therapy for PTSD

Similar to EMDR, relying on tapping or eye movement, done in a shorter amount of time, can be effective depending on the person

Prolonged Grief Disorder

Prolonged adaptation to loss associated with intense longing for and preoccupation with the deceased, leading to difficulty moving on life even after a year or more has passed. Intense grief can produce a traumatic reaction. Treatments resemble those for PTSD but are adapted for prolonged grief.

Adjustment Disorders

Anxious or depressive reactions to life stress that are generally milder than in acute stress disorder or post-traumatic stress disorder but that are nevertheless impairing in terms of interfering with work or school performance, interpersonal relationships or other areas of living. Sometimes in adolescences the stress may provoke some conduct problems. The stressful life events themselves would not be considered traumatic but it is clear that the individual is nevertheless unable to cope with the demands of the situation and some intervention is typically required. If longer than 6 months after the stress or its consequences are removed, it would be considered chronic.

Attachment Disorders

Developmentally inappropriate behaviours in which a child is unable or unwilling to form normal attachment relationships with caregiving adults. The seriously maladaptive patterns are due to inadequate or abusive child-rearing practices. Could be caused by frequent changes in the primary caregiver because of multiple foster care placements or neglect in the home. The result is a failure to meet the child’s basic emotional needs for affection and comfort or even providing for the basic necessities of daily living. 

Reactive Attachment Disorder

Attachment disorder in which a child with disturbed behaviour neither seeks out a caregiver nor responds to offers of help from one; fearfulness and sadness are often evident. Lack of responsiveness, limited positive affect and additional heightened emotionality. (Childhood only)

Disinhibited Social Engagement Disorder

Condition in which a child shows no inhibitions whatsoever in approaching adults. Perhaps child-rearing including early persistent harsh punishment, would result in a child showing this pattern. Child might engage in inappropriately intimate behaviour by showing a willingness to immediately accompany an unfamiliar adult figure somewhere without first checking back with a caregiver. (Childhood only)

Dissociative disorders

Disorders in which individuals feel detached from themselves or their surroundings, and reality, experience, and identity may disintegrate.

Depersonalization

Term given to an alteration in perception that causes someone to temporarily lose the sense of their own reality. You feel like you are detached from your own self, your own body. Often part of a serious set of conditions where reality, experiences and even our own identity seems to disintegrate.

Derealization

Situation in which the individual loses their sense of the reality of the external world. Feeling like the world around you is not real or distorted. 

Depersonalization-Derealization disorder

Dissociative disorder in which feelings of depersonalization are so severe they dominate the clients life and prevent normal functioning. Repeated experiences of feeling detached from their own thoughts or body. People experiencing these episodes remain in good contact with reality. 

Cognitive Functioning in Depersonalization-Derealization

Deficits on measures of attention, short-term memory and spatial reasoning, easily distracted and having some trouble perceiving three-dimensional objects because they tend to flatten these objects into two dimensions. Corresponds with reports of tunnel vision (Perceptual Distortions) and mind emptiness (Difficulty absorbing new information). Dysregulation in the HPA axis

Treatments for Depersonalization-Derealization Disorder

Not systematically studied

Dissociative Amnesia

Featuring the inability to recall personal information, usually of a stressful or traumatic nature.

• Treatment - usually get better on their own and remember what they have forgotten, episodes linked to current life stress that prevention of future episodes usually involves resolution of the distressing situations and increasing the strength of personal coping mechanisms

Generalized Amnesia

Condition in which a person loses memory of all personal information, including their own identity

Localized/Selective amnesia

Memory loss limited to specific times and events, particularly traumatic events. More common than general.

Dissociative Fugue

Featuring sudden, unexpected travel away from home, along with an inability to recall the past, sometimes with assumption of a new identity. Memory loss revolves around a specific incident, individuals simply leave and later find themselves in a new place unable to remember how or why they got there. Usually they have left behind an intolerable situation. Seldom happens before adolescence and usually occurs in adulthood, rare to happen after 50. Usually end abruptly. Result from escaping current life events

• Treatment - usually get better on their own and remember what they have forgotten, episodes linked to current life stress that prevention of future episodes usually involves resolution of the distressing situations and increasing the strength of personal coping mechanisms

Amok

“Running amok,” not seen in Western cultures. Individuals in this trance-like state often brutally assault and sometimes kill people or animals. If the person is not killed themselves they will probably not remember the episode. One of several “running” disorders where an individual enters a trance-like state and suddenly, imbued with a mysterious source of energy, runs or flees for a long time. Seems to resemble dissociative fugue (Running disorders)

Dissociative Trance Disorder

Altered state of consciousness in which the person believes firmly that they are possessed by spirits; considered a disorder only where there is distress and dysfunction (state is undesirable and considered pathological by members of the culture)

Dissociative Identity Disorder

Formerly known as multiple personality disorder, a disorder in which as many as one hundred personalities or fragments of personalities coexist within one body and mind. Identity is also fragmented along with amnesia. Defining feature is that certain aspects of the person’s identity are dissociated.

• Developmental window of vulnerability to the abuse that leads to DID closes at around 9 years old, after it is unlikely to develop (PTSD might be more likely) - not completely verified

Alters

Shorthand term for alter egos, the different personalities or identities in DID

Host Identity

Identity who becomes the patient and asks for treatment is usually the host. The identity who seeks treatment is rarely the original identity of the person. Host personality develops later 

Switch

Transition from one personality to another, usually instantaneous, physical transformations may occur during these (Posture, facial expressions, patterns of facial wrinkling and physical disabilities may happen)

Can DID be faked?

Hard to answer because:

• People with DID are very suggestible (possible that alters are created in response to leading questions from therapists, either from a psychotherapy session or while the person is in a hypnotic state)

Sociocognitive model 

Symptoms of DID could be accounted for by therapists who inadvertently suggested the existence of alters to suggestible individuals. The possibility of identity fragments and early trauma is socially reinforced by a therapist. 

Causes of DID

• Severe abuse from caregivers

• Trauma from other situations

• Lack of social support during or after the trauma

• The minds way of creating an escape from a bad situation - escaping past traumatic memories

Suggestibility in DID

Personality trait that is distributed normally across the population, some people are more suggestible than others, some are relatively immune to suggestibility and the majority fall in the mid-range. 

• Having imaginary childhood playmates is more common in DID, correlating to being more suggestible 

• People in a trance tend to be completely focused on one aspect of their world and become vulnerable to suggestions by hypnotist (Self-hypnosis where individuals can dissociate from most of the world around them a suggest things for themselves)

• Autohypnotic model - people who are suggestible may be able to use dissociation as a defense against trauma

• When the trauma becomes unbearable, the person’s very identity splits into multiple dissociated identities 

• Children’s ability to distinguish between reality and fantasy as they grow older may be what closes the window for developing DID 

• Less suggestible may be more likely to develop PTSD instead

Biological contributions to DID

• Certainly a biological vulnerability but it is difficult to pinpoint

• Strong evidence that sleep deprivation produces dissociative symptoms like marked hallucinatory activity, symptoms in individuals with DID seem to worsen when they feel tired 

Real and False Memories in Trauma Memories

• Memories could be a result of strong suggestions by careless therapists who assume people with this condition have been abused

• Important to remember that memories may not always be accurate or true, even if they feel true

• If abuse did happen but was not remembered because of dissociative amnesia it is important to re-experience aspects of this trauma under the direction of a skilled therapist to relieve current suffering, without it they may experience PTSD or a dissociative disorder

• Perpetrators must also be held accountable for their actions - issue that the controversy around traumatic memories may lead to less people speaking out about their abuse and the perpetrators less likely to actually be punished 

• If memories are created as a response to suggestions, false accusations could result 

• Warning that childhood memories later recovered in adulthood were of questionable reliability and should never be accepted without further context or understanding 

• Therapists should be cautious knowing that repeated suggestions can create false memories especially in young children

Treatment for DID

• Person’s identity is shattered into many different elements which is difficult to reintegrate

• Some documented successes of attempts to reintegrate identities through long-term psychotherapy

• Therapies based on accumulated clinical wisdom and procedures that have been successful for PTSD

• Fundamental goal is to identify cues or triggers that provoke memories of trauma or dissociation and to neutralize them

• Must also confront and relive the early trauma and gain control over the horrible events, at least as they recur in their mind

• Therapists must skillfully and very slowly help the patient visualize and relive aspects of the trauma until it is simply a terrible memory instead of a current event to help instill sense of control

• Because it is unconscious, aspects of the experience are often not known until they emerge during treatment

• Hypnosis is often used to access unconscious memories and bring alters into awareness

• Chronic courses and very rarely improves spontaneously

• Re-emerging memories of trauma may trigger further dissociation so therapists must be on guard against this

• Trust is absolutely essential

• Medication can be combined with therapy but there is little indication that it helps (some antidepressants might be appropriate in some cases)