Acute PTSD Disorder, Dissociative Disorders and Somatic Symptom Disorders

What defines traumatic stress?

1. A direct exposure to actual or threatened death, serious injury, or sexual violation  

   1. Sexual violation is a new part of the definition  

2. Being witness to actual or threatened death, serious injury, or sexual violation  

3. Learning of violence to a loved one  

4. Through repeated exposure to details of trauma  

What diagnoses are in Trauma and Stressor Related Disorders

• Acute Stress Disorder

• PTSD

• Adjustment Disorder

• Prolonged Grief Disorder (new to DSM-5-TR)

What is Posttraumatic Stress Disorder (PTSD)

• Extreme repose to severe stressor

• Exposure to a traumatic event that involves actual or threatened death or injury

  • e.g., war, rape, natural disaster

• Trauma leads to intense fear or hopelessness

• Lasts longer than 1 month, sometimes has a delayed onset

• Tends to be chronic

What are the 4 categories of symptoms do people with PTSD experience?

• Intrusively re-experiencing the traumatic event (must experience at least 1)

• Avoidance of stimuli (muster experience at least 1)

• Other signs of mood and cognitive changes (must experience at least 3 in adults, 2 in children)

• Increased arousal and reactivity (must experience at least 3 in adults, 2 in children)

What is intrusively re-experiencing the traumatic event in PTSD?

Repeated, distressing images or thoughts; nightmares; dissociative reactions (e.g., flashbacks)

What is avoidance of stimuli in PTSD?

Attempts to avoid thoughts, feelings related to the event; avoid people, place or activities that remind them of the event

What are other signs of mood and cognitive changes in PTSD?

Memory loss, negative thoughts and emotions, self-blame, blaming others, withdrawal

What is increased arousal and reactivity in PTSD?

Irritability, aggressiveness, recklessness or self-destructiveness, insomnia, difficulty concentrating, hyervigilance, exaggerated startle response

What is Acute Stress Disorder (ASD)

• Symptoms similar to PTSD

• Duration shorter

  • Symptoms occur between 3 days and 1 month after exposure to traumatic stress

• ASD predicts higher risk of PTSD within 2 years

What is the prevalence of PTSD in the US?

6.8%

Are women or men more likely to develop PTSD after trauma?

Women

What is a risk for PSTD in women?

Sexual violence

What is the risk for PTSD in men?

combat exposure

What percentage of children develop PTSD after experiencing trauma?

20%-40%

Who else is more likely to experience PTSD due to increased likelihood of exposure to traumatic stress?

Minorities

Who is more likely to experience trauma due to risky behaviors?

Men, young people, people with conduct disorder, extroverts all more likely to experience trauma

Who else is at an increased risk of experiencing more trauma?

people who are anxious or who have a family history of mental illness

True of False: People who developed PTSD from earlier trauma are more at risk to develop PTSD again

True

What proposes and especially high risk for PTSD?

Rape and assault

What is comorbidity in PTSD/ASD

• High for depression, anxiety disorders and substance abuse

• High for disturbing nightmares, physical symptoms

• Related to grief and relation difficulties

• Anger - usually very prominent

• Higher risk for suicide and self injuries

What are the biological causes of PTSD/ASD?

• Genetic contributions: MZ twins have a higher concordance rate than DZ twins

• The sympathetic nervous system is around and the fear response is sensitized in PTSD

What are the psychological factors of PTSD/ASD?

• Risk for PTSD depends on cognitive factors

  • Preparedness, purpose, and absence of blame

• Role of dissociation is debated

  • May not be adaptive, may be related to more PTSD

• Posttraumatic growth: positive changes resulting posttrauma

  • Linked with less depression and more positive well-being but also with more intrusive and avoidant thoughts

• Emotional processing

  • Engage emotionally with trauma

  • Articulation and organization of the chaotic experience

  • Meaning making

What are the social factors of PTSD/ASD?

• Victims of trauma are more likely to develop PTSD when the trauma is more intense, life threatening and involves greater exposure

• With less severe stressors, social support after a trauma can play a crucial role in alleviating long-term psychological damage

What is prevention for PTSD?

• Emergency Help for Trauma Victims

• Treatment of ASD may prevent PTSD

What does emergency help for trauma victims entail?

• Immediate support to trauma victims is a common goal of all early interventions

  • Three principles for combat soldiers that can be applied to civilian disasters

    1. Immediate treatment

    2. In the proximity of the battlefield

    3. With the expectation to return to the front lines upon recovery

What is therapy treatment for PTSD?

Cognitive Behavior Therapy

What is cognitive behavior therapy?

• The most effective treatment for PTSD is re-exposure to trauma

  • Prolonged exposure - direct (in vivo) or imaginal

  • Imagery rehearsal therapy - rewriting nightmare script in any way client chooses

  • Cognitive restructuring

• May initially increase symptomatology

What is the treatment for PTSD using medication?

• Antidepressants

  • Antidepressants are therapeutic re-exposure are first-line therapies for PTSD

  • Effectiveness of SSRIs is likely to (at least partially) due to the high comorbidity between PTSD and depression

  • Relapse is common if medication is stopped

Dissociative Disorders

Often controversial and disbelieved by many; true disorders appear to be rare

What is dissociation?

• Some aspect of cognition or experience becomes inaccessible to consciousness

  • Sudden disruption in the continuity of: memory, consciousness, emotions, motivation or identity

  • Some types of dissociation are harmless and common

What are the three types of dissociate disorders in the DSM-5-TR?

• Dissociate Amnesia

• Depersonalization/Derealization disorder

• Dissociative Identity Disorder

What is dissociate amnesia?

• Inability to remember important personal information, usually of a traumatic or stressful nature, that is too extensive to be ordinary forgetfulness

• Specify dissociate fugue subtype if the anemia is associated with bewildered or apparently purposeful wandering

  • Amnesia, flight and new identity

  • Sudden unexpected travel with inability to recall one’ past

• Need to rule out other possible causes of memory loss

• Usually remits spontaneously

What is depersonalization/Derealization Disorder

• Depersonalization

• Derealization

  • No psychosis or loss of memory

  • Often comorbid with anxiety, depression

  • Typical onset in adolescence; chronic

What is depersonalization?

• detachment from one’s mental processes as if “in a dream”

  • Unusual sensory experiences

  • Feelings of detachment or disconnection - “watching self from outside”

What is derealization?

• world has become unreal

  • World appears strange, foreign, dream-like

  • Incapable of experiencing emotions

What is Dissociative Identity Disorder (DID?

• Two or more distinct and fully developed personalities (alters)

  • Each has unique modes of being, thinking, feeling, acting, memories, and relationships

  • Primary alter may be unaware of existence of other alters

• Most severe of dissociate disorders

• Typical onset in childhood - rarely diagnosed until adulthood

• More common in women than men

• Often comorbid with PTSD, major depression, somatic symptoms

• Has no relation to schizophrenia

What is the frequency of DID?

• Most cases of dissociate disorders are diagnosed by a handful of ardent advocates

• The number of personalities claimed to exist in cases of DID has grown rapidly, from a handful to 100 or more

• Dissociate disordered are rarely diagnosed outside of the United States and Canada

• Frequency of diagnosis of dissociative disorders in general, and DID in particular, increased rapidly after release of the very popular book and movie sybil

What are the biological causes of Dissociative Disorders?

• Research suggests that a fragmented sleep-wake cycle helps explain dissociative symptoms

  • Sleep disturbance associated with dissociation

  • Improved sleep decreased dissociation in experimental situations

What are the psychological causes of dissociative disorders?

• Little controversy that dissociative amnesia and fugues can be precipitated by trauma

  • Trauma is suspected in DID - especially child abuse - but much of the data is retrospective

    • Disorder is so rare that no prospective studies have been done

  • The vast majority of trauma victims do not develop a dissociative disorder

• Fantasy proneness and suggestibility appear to play a key role in the development of dissociative disorders

  • “Symptoms” of DID can be induced by role playing and hypnosis

What is Iatrogenesis?

manufacture of a disorder by its treatments

What are the social factors of dissociative disorders?

• Iatrogenesis

  • Were “cases” created by the expectation of therapists?

    • For many, symptoms emerge after therapy begins

    • But this does not suggest that therapist were consciously devising their patients into experiencing dissociation

    • Or that patients were consciously creating their own disorders to please their therapists

What are treatments for Dissociative Disorders?

• Empathic and supportive therapist

• Integration of alters into one fully functioning individual (D(D)

• Improvement of coping skills

• No evidence that hypnosis or reliving of traumatic events is effective treatment

  • May actually worsen symptoms

What are somatic symptom disorders?

• Excessive concerns about physical symptoms or health

  • Problem is very real in the mind, though not the body

  • Usually numerous, constantly evolving complaints such as chronic pain, upset stomach, dizziness

  • Symptoms presented in an exaggerated, dramatic manner

  • Disorder often begins in adolescence

  • People with somatic symptoms repeatedly seek help of their physicians instead of mental health professionals

    • Leads to unnecessary medical treatment

What are the several major somatic symptom disorders listed in the DSM-5-TR?

• Functional Neurological Symptom Disorder (Conversion Disorder)

• Illness Anxiety Disorder

• Factitious Disorder

• Malingering

Psychological factors affecting other medical conditions

What is functional neurological symptoms disorder (conversion disorder)

• Sensory or motor function impaired but no known neurological cause

  • Symptoms mimic neurological disorders

  • Exs. vision impairment, seizures, partial/complete paralysis of limbs, anosmia (loss of smell)

• Make no anatomical sense

• Implies that psychological conflicts are begin converted into physical symptoms

• Onset typically adolescence or early adulthood

• Often follows life stress

What is somatic symptoms disorder?

• At least one somatic symptoms that is distressing or disrupts daily life

• Excessive thoughts, feelings, and behaviors related to somatic symptoms (such as) or health concerns, as indicated by at least one of the following:

  • Health-related anxiety

  • Disproportionate concerns about the medical seriousness of symptoms

  • Excessive time and energy devoted to health concerns

• Duration of at least 6 months

What is illness anxiety disorder?

• Fear or belief that one is suffering from a physical illness, but physical symptoms missing/minor

• Disorder is preoccupying, enduring; leads to substantial impairment in life functioning

• Excessive behaviors (e.g., checking for signs of illness, seeking reassurance) or maladaptive avoidance (e.g., avoiding medical care)

• No more than mild somatic symptoms are present

• Preoccupation lasts at least 6 months

What is factitious disorder?

• Fabrication or induction of physical or psychological symptoms, injury or disease

• Deceptive behavior is present in the absence of obvious external rewards

• Unlike malingering, is motivated primarily by a desire to assume the sick role theater than by a desire for external gain

What is malingering?

Intentionally faking psychologically or somatic symptoms to achieve some external gain

What is facetious disorder imposed on self?

The person presents themselves to others as ill, impaired, or injured

• Extensive knowledge of medical terms and disease

• Vague, inconsistent symptoms

• Seeking treatment from many providers

What is factitious disorder imposed on another?

the person fabricates or induces symptoms in another person and then presents that person to others as ill, impaired, or injured

• Münchausen syndrome by proxy was the former name

• Usually involves a parent harming a child

What is the prevalence of functional neurological symptom disorder (conversion disorder)?

rare, less than 1% of the population

What is the prevalence of somatic symptom disorder?

5-7% of the population

What is the prevalence of illness anxiety disorder?

1-10% of the population

What is the prevalence of factitious/malingering?

Unclear

Who are the somatic symptom disorders more prevalent in?

More common among women, lower SES and rural areas

What do somatic symptom disorders co-occur with?

depression, anxiety, and antisocial personality disorder

What are the biological factors of somatic symptom disorders?

• Difficulties with diagnosis by exclusion and medically unexplained syndromes

• No support for genetic influence - concordance rates in MZ twin pairs do not differ from DZ twin pairs

What are psychological factors of somatic symptom disorders?

• Sometimes can be triggered by traumatic stress

• Cognitive factors

  • Tendency to amplify somatic symptoms and overreact with overly negative interpretations

• Learning the sick role

  • Behaviors reinforced by attention or sympathy - learn to be “sick” and benefit from that role

What are the treatments for the somatic symptom disorders?

• Few controlled treatment outcome studies

  • Cognitive behavioral therapy

    • Identify and change triggering emotions

    • Change cognitions about symptoms

    • Replace sick role behaviors with more appropriate social interactions

    • Reward successful coping and adaption to chronic pain \

  • Antidepressants

  • Patients are likely to refuse a referral to a mental health professional