• Stress has two components

  • Stressor: The event that creates the demands

  • Stress Response: The person’s reactions to the demands

• Our response to stressors is influenced by the way we judge both the events and our capacity to react to them in an effective way

• When we view a stressor as threatening, a natural reaction is arousal and a sense of fear

• Stress reactions are often at play in psychological disorders

Stress and Arousal: The Flight-or-Fight Response

• Hypothalamus activates the autonomic nervous system and the endocrine system

  • Autonomic Nervous System: Extensive network of nerve fibers that connect the central nervous system to all the other organs of the body

    • Controls the involuntary activities of the organs

    • ex: breathing, heartbeat, blood pressure, perspiration, etc

  • Endocrine System: Network of glands located throughout the body

• Brain-body pathways in which the ANS and the endocrine system produce arousal

  • Sympathetic Nervous System Pathway: A group of ANS fibers that work to quicken our heartbeat and produce the other changes that we come to experience as fear or anxiety. Excited when we face a dangerous situation. After the danger passes, the parasympathetic nervous system helps return bodily processes to normal

  • Hypothalamic-Pituitary-Adrenal Pathway: When we are faced by stressors, the hypothalamus signals the pituitary gland to secrete stress hormones

• Fight-or-Flight response - these systems arouse our body and prepare us for a response to danger

Acute and Posttraumatic Stress Disorders

• Traumatic Event: Event in which a person is exposed to actual or threatened death, serious injury, or sexual violation

• Acute Stress Disorder: A disorder in which a person experiences fear and related symptoms soon after a trauma but for less than a month

• PTSD: A disorder in which a person experiences fear and related symptoms long after a traumatic event

• At least half of all cases of acute stress disorder develop into ptsd

• Increased arousal, negative emotions, and guilt

  • Hyperalertness: excessively alert

  • Easily startled

  • Trouble concentrating

  • Develop sleep problems

  • Display anxiety, anger, or depression, and these emotions fluctuate (emotional dysregulation/labile mood)

  • May feel extreme guilt (survivors guilt or guilt over what they had to do to survive)

• Reexperiencing the traumatic event

  • Recurring thoughts, memories, dreams, or nightmares connected to the event

  • Flashbacks

• Avoidance of activities / thoughts / feelings / conversations that remind them of the traumatic event

• Reduced responsiveness and dissociation

  • Feel detached from other people

  • Unresponsive to external stimuli

  • Lose interest in activities that once brought enjoyment

  • Dissociation: Psychological separation. feel dazed, have trouble remembering things, experience depersonalization or have sense of derealization

    • Depersonalization: Feeling that their conscious state or body is unreal

    • Derealization: Feeling that the environment is unreal or strange

• People who experience symptoms of dissociation and unresponsiveness as part of their stress syndrome tend to be more impaired and distressed than other sufferers

• Acute or posttraumatic stress disorder can occur at any age

• People w low incomes as twice as lille to experience stress disorders

What Triggers Acute and Posttraumatic Stress Disorders?

• Combat

  • 29% of all Vietnam veterans suffered an acute or posttraumatic stress disorder

  • 22% of Vietnam veterans have had at least some stress symptoms

  • 10% of the veterans of that war still deal with posttraumatic stress symptoms

• Disasters (ex: earthquakes, floods, tornadoes, fires, airplane crashes serious car accidents)

• Abuse and Victimization

  • Over one-third of all victims of physical or sexual assault develop PTSD

  • Half of all people directly exposed to terrorism or torture may develop PTSD

  • Sexual Assault / Rape: Forced sexual intercourse or another sexual act committed against a nonconsenting person or intercourse between an adult and an underage person

    • Most rapists are men and most victims are women

    • 71% of victims are raped by acquaintances, intimates, or relatives

  • Psychological impact of rape on a victim is immediate and may last a long time

    • Enormous distress during the week after the assault

    • Stress continues to rise for the next three weeks

    • Maintains peak level of stress for another month

    • Starts to improve

  • Can last anywhere from 3 months to 18+

  • High levels of anxiety, suspiciousness, depression, self-esteem problems, self-blame, flashbacks, sleep problems, sexual dysfunction

• Terrorism: Many people develop immediate and long-term psychological effects when they are victims of terrorism or live under the threat of terrorism

  • 911, 2004 commuter train bombings in Madrid, 2013 Boston Marathon bombing, etc.

• Torture: The use of brutal, degrading, and disorienting strategies to reduce victims to a state of utter helplessness

  • Physical torture: beatings, waterboarding, electrocution

  • Psychological torture: threats of death, mock executions, verbal abuse, degradation

  • Sexual torture: rape, violence to the genitals, sexual humiliation

  • Torture through deprivation: sleep, sensory, social, nutritional, medical, or hygiene deprivation

  • Victims often experience physical ailments as a result of their ordeal (scarring, fractures, neurological problems, chronic pain)

  • 30-50% of torture victims develop PTSD

Why Do People Develop Acute and Posttraumatic Stress Disorders?

• Biological factors

  • Brain-Body Stress Pathways: people who develop PTSD react with especially heightened arousal in the stress pathways

    • Even before a trauma, these people’s pathways are overly reactive to modest stressors, setting up a predisposition to PTSD

    • After a severe trauma, these pathways become even more overly reactive

    • There’s abnormal activity of cortisol in survivors of severe stresses

  • Brain’s stress circuit: Dysfunction in the stress circuit contributes to the symptoms of PTSD

    • The interconnection between the amygdala and prefrontal cortex is flawed

      • Amygdala (springs into action when the person confronts a stressor) activity is too high

      • Prefrontal cortex (evaluates the message and sends signals back to the amygdala to slow down) activity is too low

    • Dysfunctions in the hippocampus and in its connection to the amygdala may result in unchecked emotional memories and persistent arousal symptoms that characterize PTSD, as well as the dissociations found in many cases

  • Inherited Predispositions: Certain individuals inherit a tendency for overly-reactive brain-body stress pathways and a dysfunctional brain stress circuit

    • Genes

    • People suffering from PTSD are more likely to transmit relevant biological abnormalities to their children

• Childhood experiences

  • Young children who are traumatized (chronically neglected,  abused, etc) develop overly reactive stress pathways and a dysfunctional brain stress circuit

  • Certain childhood experiences increase a person’s risk for later PTSD

    • Poverty

    • Assault, abuse, catastrophe

    • Multiple traumas

    • Parental separation or divorce

    • Living with family members suffering from psychological disorders

• Personal Styles: People with certain personalities, attitudes, and coping styles are particularly likely to develop PTSD

  • People who are highly anxious

  • People who generally view life’s negative events as beyond their control

  • People who generally find it difficult to derive anything positive from unpleasant situations

  • People with a resilient style of personality as less likely than others to develop PTSD

    • Resilience: the ability of a person to adapt well and cope effectively in the face of life adversity

    • Young children who are regularly exposed to manageable stress often develop heightened resilience

    • The brain-body stress pathways and brain stress circuits of resilient persons tend to operate better than those of other people

• Social Support Systems: People whose social and family support systems are weak are more likely to develop PTSD after a traumatic event

• Severity and nature of the traumas: The more severe or prolonged the trauma and the more direct one’s exposure to it, the greater the likelihood of developing a stress disorder

  • Traumas that increase the risk of stress disorders: mutilation, severe physical injury, sexual assault, witnessing the injury or death of other people

  • Encounters with multiple or recurring traumas can lead to complex PTSD

    • Complex PTSD is PTSD + profound disturbances in their emotional control, self-control, and relationships

• Developmental Psychopathology Perspective: Focuses on the intersection and context of important variables at key points of time throughout an individual’s lifespan

  • Certain people have a biological predisposition for overreactivity in their brain-body stress pathways and for dysfunction in their brain’s stress circuit that sets the stage for the later development of PTSD

  • The timing of stressors and traumas over the course of development has a profound influence on whether an individual will develop PTSD

    • Extreme stressors in childhood disrupt and alter newly developing brain-body stress pathways and brain stress circuits

  • Multifinality: People with similar beginnings may wind up at different end points

  • Equifinality: Different developmental pathways may lead to the same end point

How Do Clinicians Treat Acute and Posttraumatic Stress Disorders?

• Treatment for Combat Veterans

  • Antidepressant Drugs

    • Helpful for symptoms of increased arousal and negative emotions

    • Less helpful for symptoms of recurrent negative memories, dissociations, and avoidance behaviors

    • Half of PTSD patients who take antidepressants experience symptom reductions

  • Cognitive-Behavioral Therapy

    • Cognitive Processing Therapy: Therapists guide the veterans to examine and change the dysfunctional attitudes and styles of interpretation they have developed as a result of their traumatic experiences

    • Mindfulness-Based Techniques: Help clients become more accepting and less judgmental of their recurring thoughts, feelings, and memories

    • Behavioral: apply exposure techniques when treating veterans with PTSD

    • Virtual Reality Therapy

    • Prolonged Exposure: A treatment approach in which clients confront not only trauma-related objects and situations, but also their painful memories of traumatic experiences

    • Eye Movement Desensitization and Processing (EMDR): An exposure treatment in which clients move their eyes in a rhythmic manner from side to side while flooding their minds with images of objects and situations they ordinarily avoid

  • Couple and Family Therapy: With the help and support of their family members, veterans with PTSD may come to

    • Examine their impact on others

    • Learn to communicate better

    • Improve their problem-solving skills

    • Reestablish feelings of closeness

  • Group Therapy: Veterans meet with other like themselves to share experiences and feelings, develop insights, and give mutual support

    • Veteran Outreach Centers

    • Treatment programs in Veterans Administration hospitals and mental health clinics

• Psychological Debriefing: A form of crisis intervention that has victims of trauma talk extensively about their feelings and reactions within days of the critical incident

  • Also called critical incident stress debriefing

  • May encourage victims to dwell too long on their traumatic events they’ve experienced

Dissociative Disorders

• Disorders marked by major changes in memory that don’t have clear physical causes

• One part of a person’s memory or identity becomes separated from other parts of their memory/identity

Dissociative Amnesia

• People are unable to recall important personal events and information

• An episode of amnesia is directly triggered by a traumatic or upsetting event

• Localized Amnesia: A person loses all memory of events that took place within a limited period of time, almost always beginning with some very disturbing occurrence

  • Most common type of dissociative amnesia

  • Forgotten period is called the amnestic episode

  • During an amnestic episode people may appear confused and they seem unaware of their memory difficulties

• Selective Amnesia: A person will remember some, but not all, events that took place during a period of time

  • Second most common form of dissociative amnesia

• Generalized Amnesia: Loss of memory extends back to times long before the upsetting period

  • In extreme cases, the person might not even recognize relatives and friends

• Continuous Amnesia: The person may forget new and ongoing experiences as well as what happened before and during the traumatic event

• At least 2 percent of all adults experience dissociative amnesia in a given year

• Childhood abuse can also trigger dissociative amnesia

• Personal impact of dissociative amnesia depends on how much is forgotten

• Dissociative Fugue: An extreme version of dissociative amnesia

  • People not only forget their personal identities and details of their past lives but also flee to an entirely different location

  • Fugues tend to end abruptly

  • As these people recover their past, some forget the events of the fugue period

  • The majority of people who go through a dissociative fugue regain most of all of their memories and never have a recurrence

  • Fugues are brief and reversible, so there are few aftereffects

Dissociative Identity Disorder

• People have two or more separate identities that may not always be aware of each other’s memories, thoughts, feelings, and behavior

• Subpersonalities / Alternate Personalities: The two or more distinct personalities found in individuals suffering with did

• At any given time, one of the subpersonalities takes center stage and dominates the person’s functioning

• Usually one subpersonality, called the primary / host personality, appears more often than the others

• Switching: The transition from one subpersonality to another

  • Usually sudden and may be dramatic

  • Usually triggered by a stressful event

  • Clinicians can trigger a switch with hypnotic suggestion

• Most cases are first diagnosed in late adolescence or early adulthood

• Symptoms begin in early childhood after episodes of trauma or abuse

• Women receive this diagnosis at least three times as often as men

• How do subpersonalities interact?

  • Varies from case to case

  • Mutually Amnesic Relationships: The subpersonalities have no awareness of each other

  • Mutually Cognizant Patterns: Each subpersonality is well aware of the rest

  • One-way Amnesic Relationships: some subpersonalities are aware of others, but the awareness is not mutual

    • Most common relationship pattern

    • Conscious Subpersonalities: The subpersonality that is aware and is a quiet observer. Makes itself known through indirect means

      • Auditory hallucinations

      • Automatic Writing: The current personality may find itself writing down words over which it has no control

  • Bonus: What relationship do the subpersonalities Mark, Jake, and Steven have in the Marvel show MoonKnight?

  • On average, women w/ did have 15 subpersonalities and men w did have 8

  • Often, subpersonalities emerge in groups of 2 or 3 at a time

• How do subpersonalities differ?

  • Identifying features - age, gender, race, and family history

  • Abilities and preferences - different subpersonalities to different abilities

  • Physiological responses

    • Differences in blood pressure levels

    • Differences in allergies

    • Brain activities measured on an electroencephalograph to measure evoked potentials - brain activities of personalities are unique

• How common is DID?

  • Some researchers argue that many or all cases of did are iatrogenic

    • Iatrogenic: Cases that are unintentionally produced by practitioners

  • Many cases of DID first come to attention while the person is already in treatment for a less serious problem

  • Many people seek treatment because they have noticed time lapses throughout their lives or because relatives and friends have observed their subpersonalities

  • The number of ppl diagnosed w DID increased in the 1980s and 90s and decreased again in the 21st century

  • Clinical theorists estimate 1 percent of the population in the US and other Western countries displays DID

How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder?

• Psychodynamic view

  • Dissociative disorders are caused by repression

    • People fight off anxiety by unconsciously preventing painful memories, thoughts, or impulses from reaching awareness

    • Ppl with dissociative amnesia and did repress their memories excessively

  • Dissociative Amnesia is a single episode of massive repression

    • A person unconsciously blocks the memory of an extremely upsetting event to avoid the pain of facing it

    • Repressing may be their only protection from overwhelming anxiety

  • Dissociative Identity Disorder is thought to result from a lifetime of excessive repression

    • Continuous use of repression is motivated by traumatic childhood events

    • Children who experience trauma pretend to be another person looking on safely from afar

    • Abused children come to fear the impulses that they believe are the reasons for their excessive punishments

    • They unconsciously try to disown and deny “bad” thoughts and impulses by assigning them to other personalities

• State-Dependent Learning: A Cognitive-Behavioral View

  • State-Dependent Learning: If people learn something when they are in a particular situation or state of mind, they are likely to remember it best when they are again in that same condition. can also be associated with mood states

  • A particular level of arousal will have a set of remembered thoughts, events, and skills attached to it

  • People who are prone to develop dissociative disorders have state-to-memory links that are unusually rigid and narrow

    • Each of their thoughts, memories, and skills may be tied exclusively to a particular state of arousal

    • They recall a given event only when they experience an arousal state almost identical to the state in which the memory was first acquired

• Self-hypnosis: The process of hypnotizing oneself, sometimes for the purpose of forgetting unpleasant events

  • People who are hypnotized enter a sleeplike state in which they can become very suggestible

  • Hypnosis can help people remember events that occurred and were forgotten years ago

  • Hypnotic Amnesia: Hypnosis can make people forget facts, events, and personal identities

How Are Dissociative Amnesia and Dissociative Identity Disorder Treated?

• Dissociative Amnesia

  • Psychodynamic Therapy: Therapists guide patients to search their unconscious in the hope of bringing forgotten experiences back to consciousness

  • Hypnotic Therapy / Hypnotherapy: Therapists hypnotize patients and guide them to recall their forgotten events

  • Drug Therapy

    • Sodium Amobarbital (amytal)

    • Sodium Pentobarbital (pentothal)

    • Uses drugs that calm people and free their inhibitions

    • Helps patients recall anxiety-producing events

• Dissociative Identity Disorder: Therapists help patients…

  • recognize fully the nature of their disorder

    • Therapists try to bond with the primary personality and each of the subpersonalities

    • Some therapists introduce the subpersonalities to each other (hypnosis, video)

  • recover the gaps in their memory

    • Use the same approaches applied in dissociative amnesia

    • Some subpersonalities may keep denying experiences that the others recall

    • One of the subpersonalities may assume a protector role to prevent the primary personality from suffering the pain of recollecting traumatic experiences

  • integrate their subpersonalities into one functional personality

    • Fusion: Final merging of two or more subpersonalities

    • Subpersonalities may see integration as a form of death

    • Once the subpersonalities are integrated, further therapy is needed to maintain the complete personality

    • Some patients continue to resist full integration

Depersonalization-Derealization Disorder

• People feel as though they’ve become detached from their own mental processes or bodies or are observing themselves from the outside

• Depersonalization: The sense that one’s own mental functioning or body are unreal or detached

  • Feel like they’ve become separated from their body and are observing themselves from outside

  • Doubling: Mind seems to be floating a few feet above them

  • Body parts feel foreign

  • Emotional state: mechanical, dreamlike, dizzy

  • They are aware that their perceptions are distorted, so they remain in contact with reality

• Derealization: The sense that one’s surroundings are unreal or detached

• Symptoms of depersonalization-derealization disorder are persistent / recurrent, cause considerable distress, and may impair social relationships and job performance

• Comes on suddenly and may be triggered by extreme fatigue, physical pain, intense stress, or recovery from substance abuse