Study Guide on Stress-Related Disorders and Dissociative Disorders

Disorders Specifically Associated With Stress

  • Disorders associated with stress are directly linked to exposure to a stressful or traumatic event or a series of such events.

    • Key Point: An identifiable stressor is essential for diagnosis but is not sufficient; many individuals exposed to stressors do not develop disorders.

    • Stressful events can range from normal life experiences (e.g., divorce, socioeconomic issues, bereavement) to highly traumatic events (e.g., torture, combat).

List of Disorders Associated with Stress

  • Post-traumatic Stress Disorder (PTSD)

  • Complex Post-traumatic Stress Disorder

  • Prolonged Grief Disorder

  • Adjustment Disorder

  • Reactive Attachment Disorder

  • Disinhibited Social Engagement Disorder

  • Other Specified Disorder Specifically Associated with Stress

  • Disorder Specifically Associated with Stress, Unspecified

Post-traumatic Stress Disorder (PTSD)

Essential Features

  • Diagnosis Requirement: Exposure to an extremely threatening or horrific event is mandatory, which may include natural or man-made disasters, combat experiences, serious accidents, sexual violence, torture, and learning about violent deaths of loved ones.

Characteristic Symptoms

  1. Re-experiencing the Traumatic Event:

    • The traumatic event is relived through vivid intrusive memories, flashbacks, or nightmares.

    • Flashbacks: Can range from mild (transient sense of reliving) to severe (loss of present awareness).

    • Strong emotional reactions involving intense sensations of fear or horror accompany these experiences.

  2. Avoidance Behavior:

    • Individuals actively avoid reminders of the trauma.

    • This can include avoiding thoughts, memories, conversations, and even changing their environment (e.g., relocating to avoid reminders).

  3. Increased Arousal:

    • Persistent hypervigilance or exaggerated startle reactions.

    • People may exhibit behaviors to ensure safety, such as avoiding certain situations.

Functional Impairment

  • Major impairment across personal, family, social, educational, or occupational functioning is necessary for diagnosis.

    • Even if functioning is maintained, it often requires considerable effort.

Additional Clinical Features

  • Common symptoms include:

    • Dysphoria, dissociative symptoms, somatic complaints, suicidal ideation, anxiety, social withdrawal, substance use, panic.

    • Emotional experiences may involve anger, shame, sadness, humiliation, and survivor guilt.

Common Signs and Symptoms of PTSD (Table 14-2)

  • Intrusive memories or flashbacks of the event.

  • Frightening dreams.

  • Avoidance of reminders or stimuli related to the event.

  • Acute anxiety, panic, or aggression episodes.

  • Insomnia and heightened startle reactions.

  • Emotional blunting and detachment.

Course Features

  • Symptoms can begin at any stage post-trauma, typically within 3 months but can occur years later.

  • Significant variability exists over time; some individuals may recover within 3 months, others may have persistent symptoms.

Etiology

  1. Stressor:

    • The stressor is crucial for the development of PTSD, but is not enough on its own; genetic and psychosocial factors also influence outcomes.

  2. Risk Factors:

    • A significant portion of the population experiences trauma (60% males, 50% females), yet PTSD prevalence is around 8%.

    • Those with a severe trauma histories show a dose-response relationship to PTSD symptoms.

  3. Biological Factors:

    • Neurotransmitter systems involve norepinephrine, dopamine, and the hypothalamic-pituitary-adrenal (HPA) axis; hyperactivity is noted in PTSD patients.

  4. Noradrenergic System:

    • Symptoms like increased blood pressure or heart rates indicate a hyperactive state in the noradrenergic system.

Vulnerability Factors (Table 14-1)

  • Childhood trauma, personality disorder traits, inadequate support systems, female gender, recent stressors, and external locus of control.

Good Prognostic Factors

  • Quick onset and short duration of symptoms, good premorbid functioning, strong social support systems.

Treatment Approaches

  1. Pharmacotherapy:

    • SSRIs (e.g., sertraline, paroxetine) are considered first-line treatments.

    • Buspirone is potentially effective.

  2. Psychotherapy:

    • Individualized psychodynamic psychotherapy may help, involving reconstruction of traumatic events but must be managed carefully to avoid overwhelming patients.

Complex Post-traumatic Stress Disorder

Essential Features

  • Diagnosis requires exposure to prolonged or repetitive events that are extremely threatening. Yu
    Examples of such events include concentration camps, slavery, and prolonged domestic violence.

Symptoms and Characteristics

  • Similar to PTSD but with major emphasis on difficulties in affect regulation and persistent beliefs of worthlessness.

  • Individuals may experience extreme emotional reactions, self-destructive behaviors, and difficulties relating to others.

  • Significant impairments in various functioning areas are a key characteristic.

Prolonged Grief Disorder

Essential Features

  1. Diagnosis requires a history of bereavement involving close relations.

  2. Symptoms include pervasive grief responses like longing for the deceased and persistent emotional pain.

  3. Grief persists long beyond typical cultural norms, resulting in significant functional impairments.

Additional Clinical Features

  • A focus on circumstances of the death, problems in recalling positive memories of the deceased, and increased substance use may be present.

Adjustment Disorder

Definition

  • A maladaptive reaction to identifiable psychosocial stressors emerging within a month.

  • Frequently associated with changes like divorce, job loss, diagnosis of illness.

Characteristic Symptoms

  • Characterized by excessive worry and preoccupation following stressor.

  • Symptoms must not be better accounted for by other mental disorders.

Resolution

  • Symptoms typically resolve within 6 months post-stressor removal, but functioning is impaired if at all maintained.

Dissociative Disorders

Definition

  • Characterized by involuntary disruptions in the integration of identity, sensations, perceptions, memories, etc.

  • Typically occurs in response to trauma.

Types of Dissociative Disorders Include:

  • Dissociative Neurological Symptom Disorder

  • Dissociative Amnesia

  • Trance Disorder

  • Possession Trance Disorder

  • Dissociative Identity Disorder

  • Partial Dissociative Identity Disorder

  • Depersonalization-Derealization Disorder

Key Features of Each Disorder

Dissociative Neurological Symptom Disorder

  • Involuntary disruptions in normal functions without a recognized neurological condition.

Dissociative Amnesia

  • Inability to recall important autobiographical memories not due to common forgetting or consistent with other disorders.

Dissociative Identity Disorder

  • Characterized by the presence of two or more distinct personality states with interruptions in identity and memory.

Depersonalization-Derealization Disorder

  • Involves experiences of detachment from self (depersonalization) or surroundings (derealization) while maintaining reality testing.

Treatment Strategies for Dissociative Disorders

  1. Psychotherapy:

    • Insight-oriented psychotherapy tailored to the individual.

  2. Pharmacotherapy:

    • Medications as adjuncts, focusing on symptom management where applicable.