DB5 - Chapter 5: Trauma
Gillianrich
comerfund9e_lectureslides_ch05.pptxDisorders of Trauma and Stress
Chapter 5
Fundamentals of Abnormal Psychology
RONALD J. COMER | JONATHAN S. COMER| ninth edition
Stress and Arousal (part 1)
Components of stress
Stressor
Event that creates demands
Causes fear when viewed as threatening
Stress response
Person's reactions to demands
Extraordinary stress and trauma
Can play a central role in certain psychological disorders
Fear is a “package” of responses that are physical, emotional, and cognitive.
People who experience a large number of stressful events are particularly vulnerable to the onset of anxiety and other psychological disorders.
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Stress and Arousal (part 2)
Stress and psychological disorders
Acute stress disorder
Posttraumatic stress disorder (PTSD)
DSM-5 lists these as “trauma and stressor-related disorders”
Stress and physical (psychophysiological) disorders
DSM-5 lists these under “psychological factors affecting medical condition”
Stress and Arousal: The Fight-or-Flight Response (part 1)
Features of arousal and fear are set in the hypothalamus
Two important systems are activated
Autonomic nervous system (ANS)
An extensive network of nerve fibers that connect the central nervous system (the brain and spinal cord) to all other organs of the body
Endocrine system
A network of glands throughout the body that release hormones
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The Autonomic Nervous System (ANS)
When the sympathetic division of the ANS is activated, it stimulates some organs and inhibits others. The result is a state of general arousal. In contrast, activation of the parasympathetic division leads to an overall calming effect.
Sympathetic nervous system: The nerve fibers of the autonomic nervous system that quicken the heartbeat and produce other changes experienced as arousal.
Parasympathetic nervous system: The nerve fibers of the autonomic nervous system that help return bodily processes to normal.
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Stress and Arousal: The Fight-or-Flight Response (part 2)
Two pathways by which ANS and the endocrine system produce arousal and fear reactions
Sympathetic nervous system pathway
Hypothalamic-pituitary-adrenal pathway
The Endocrine System: The HPA Pathway
When we face a dangerous situation, the hypothalamus first excites the sympathetic nervous system, which stimulates key organs either directly or indirectly.
When the perceived danger passes, the parasympathetic nervous system helps return body processes to normal.
The reactions on display in these two pathways are collectively referred to as the fight-or-flight response.
Each person has a particular pattern of autonomic and endocrine functioning and, therefore, a particular way of experiencing arousal and fear.
Hypothalamic-pituitary-adrenal pathway: The hypothalamus signals the pituitary gland, which stimulates the adrenal cortex to release corticosteroids (stress hormones) into the bloodstream.
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Acute and Posttraumatic Stress Disorders (part 1)
Acute stress disorder
Symptoms begin within four weeks of event and last for less than one month
Posttraumatic stress disorder (PTSD)
Symptoms may begin either shortly after event, or months or years afterward
As many as 80 percent of all cases of acute stress disorder develop into PTSD
Lingering impact More than four decades after the Vietnam War, over a quarter million veterans of that war are still suffering from PTSD. Until his death in 2016, one such veteran was King Charsa Bakari Kamau. He is seen here playing the piano at a mall in Denver, Colorado, an avocation that he considered to be his best therapy.
During and immediately after trauma, we may temporarily experience levels of arousal, anxiety, and depression. For some, symptoms persist well after the trauma. These people may be suffering from:
Acute stress disorder
Posttraumatic stress disorder (PTSD)
The precipitating event usually involves actual or threatened serious injury to self or others. The situations that cause these disorders would be traumatic to anyone (unlike other anxiety disorders).
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Acute and Posttraumatic Stress Disorders (part 2)
Aside from differences in onset and duration, symptoms of acute stress disorders and PTSD are almost identical
Increased arousal, anxiety, and guilt
Reexperiencing the traumatic event
Avoidance
Reduced responsiveness and dissociation
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Acute and Posttraumatic Stress Disorders (part 3)
Checklist
A person is exposed to a traumatic event—death or threatened death, severe injury, or sexual violation
A person experiences at least one of the following intrusive symptoms:
Repeated, uncontrolled, and distressing memories
Repeated and upsetting trauma-linked dreams
Dissociative experiences such as flashbacks
Significant upset when exposed to trauma-linked cues
Pronounced physical reactions when reminded of the event(s)
Acute and Posttraumatic Stress Disorders (part 4)
Checklist (continued)
The person continually avoids trauma-linked stimuli
The person experiences negative changes in trauma-linked cognitions and moods, such as being unable to remember key features of the event(s) or experiencing repeated negative emotions
The person displays conspicuous changes in arousal or reactivity, such as excessive alertness, extreme startle responses, or sleep disturbances
The person experiences significant distress or impairment, with symptoms lasting more than a month
Acute and Posttraumatic Stress Disorders (part 5)
Can occur at any age and affect all aspects of life
Affect at least 3.5 percent of people in the United States each year
More common among women (2:1) and people with low incomes
Two-thirds of affected people seek treatment at some point
More likely to be caused by some event—combat, disasters, abuse, and victimization
Approximately 7 to 9 percent of people in the United States are affected sometime during their lifetime.
After trauma, approximately 20 percent of women and 8 percent of men develop disorders.
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Acute and Posttraumatic Stress Disorders (part 6)
Triggers
Combat
Disasters and accidents
Victimization
Sexual assault and rape
Terrorism
Torture
Combat and stress disorders are called “shell shock” or “combat fatigue.”
Post–Vietnam War clinicians discovered that soldiers also experienced psychological distress after combat.
As many as 29 percent of Vietnam combat veterans suffered acute or posttraumatic stress disorders.
An additional 22 percent had some stress symptoms.
Some 10 percent are still experiencing problems.
A similar pattern is currently unfolding among 2.7 million veterans of wars in Afghanistan and Iraq.
Acute or posttraumatic stress disorders may also follow natural and accidental disasters.
Types of disasters include earthquakes, floods, tornadoes, fires, airplane crashes, and serious car accidents.
Because they occur more often, civilian traumas have been implicated in stress disorders at least 10 times as often as combat traumas.
Victimization and stress disorders:
People who have been abused or victimized often experience lingering stress symptoms.
Research suggests that more than one-third of all victims of physical or sexual assault develop PTSD.
Terrorism and torture:
The experience of terrorism or the threat of terrorism often leads to posttraumatic stress symptoms, as does the experience of torture.
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Acute and Posttraumatic Stress Disorders (part 7)
Why do people develop acute and posttraumatic stress disorders?
Biological factors
Childhood experiences
Personal styles
Social support systems
Severity and nature of the traumas
Let’s take a look at each of these.
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Acute and Posttraumatic Stress Disorders (part 8)
Why do people develop acute and posttraumatic stress disorders?
Biological factors
Brain–body stress pathways
Brain’s stress circuit
Inherited predisposition
Childhood experiences
Chronic neglect or abuse
Poverty
Parental separation or divorce
Catastrophe
Family members with psychological disorders
Some research suggests abnormal neurotransmitter and hormone activity (especially norepinephrine and cortisol).
Once a stress disorder sets in, further biochemical arousal and damage may also occur (especially in the hippocampus and amygdala).
There may be a biological/genetic predisposition to such reactions.
Researchers have found that certain childhood experiences increase risk for later stress disorders.
Risk factors:
An impoverished childhood
Psychological disorders in the family
The experience of assault, abuse, or catastrophe at an early age
Being younger than 10 years old when parents separated or divorced
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Acute and Posttraumatic Stress Disorders (part 9)
Why do people develop acute and posttraumatic stress disorders?
Personal styles
Preexisting high anxiety and negative worldview versus resiliency and positive attitudes
Social support systems
Weak family and social support systems
Some studies suggest that people with certain personalities, attitudes, and coping styles are particularly likely to develop stress disorders.
Risk factors:
Preexisting high anxiety
Negative worldview
A set of positive attitudes (called resiliency or hardiness) is protective against developing stress disorders.
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Acute and Posttraumatic Stress Disorders (part 10)
Why do people develop acute and posttraumatic stress disorders?
Severity and nature of the trauma
More severe or prolonged trauma
More direct exposure to trauma
Intentionally inflicted trauma
Mutilation, severe physical injury, or sexual assault
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Acute and Posttraumatic Stress Disorders (part 11)
Why do people develop acute and posttraumatic stress disorders?
Developmental psychopathology perspective
Timing of stressors and traumas over developmental course and
Inherited or acquired biological predisposition for overreactivity in brain–body stress pathways and dysfunction in brain stress circuit
Principles of multifinality and equifinality
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Acute and Posttraumatic Stress Disorders (part 12)
How do clinicians treat acute and posttraumatic stress disorders?
About half of all cases of PTSD improve within 6 months; the remainder may persist for years
Treatment procedures vary depending on the type of trauma
General goals
End lingering stress reactions
Gain perspective on painful experiences
Return to constructive living
Acute and Posttraumatic Stress Disorders (part 13)
How do clinicians treat acute and posttraumatic stress disorders?
Combat veterans
Antidepressant drugs
Cognitive-behavioral therapy
Cognitive processing therapy
Mindfulness-based techniques
Exposure techniques; prolonged exposure
Eye movement desensitization and reprocessing (EMDR)
Couple or family therapy
Group therapy
Combination of some of the above
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MindTech: Virtual Reality Therapy: Better Than the Real Thing?
Exposure-based treatment is the best intervention for people with PTSD
Earlier treatment: In vivo exposure more effective than covert exposure
Today: Virtual reality exposure now standard in PTSD treatment
Virtual reality therapy is becoming more common in treatment of other anxiety disorders and phobias
“Virtual” exposure: Back to a battle scene in Iraq
Exposure-based therapy may be the single most helpful intervention for people with PTSD.
In virtual reality therapy, clients use wraparound goggles and joysticks to navigate their way through a computer-generated military convoy, battle, or bomb attack in a landscape that looks like Iraq or Afghanistan.
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Acute and Posttraumatic Stress Disorders (part 14)
How do clinicians treat acute and posttraumatic stress disorders?
Couple or family therapy
Counseling for spouses and children
Group therapy
Rap groups
Individual counseling
Combination of some of the above
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Acute and Posttraumatic Stress Disorders (part 15)
How do clinicians treat acute and posttraumatic stress disorders?
Psychological debriefing (critical incident stress debriefing)
Crisis intervention in which victims of trauma talk extensively about their feelings and reactions within days of the critical incident
Unsupported in research
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Dissociative Disorders (part 1)
Group of disorders triggered by traumatic events
When such changes in memory lack a clear physical cause, they are called “dissociative” disorders
One part of the person's memory typically seems to be dissociated, or separated, from the rest
The key to our identity—the sense of who we are and where we fit in our environment—is memory.
Our recall of past experiences helps us to react to present events and guides us in making decisions about the future.
People sometimes experience a major disruption of their memory:
They may not remember new information.
They may not remember old information.
Dissociative symptoms are often found in cases of acute or posttraumatic stress disorders.
When such symptoms occur as part of a stress disorder, they do not necessarily indicate a dissociative disorder (a pattern in which dissociative symptoms dominate).
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Dissociative Disorders (part 2)
Kinds of dissociative disorders
Dissociative amnesia
Dissociative fugue
Dissociative identity disorder (multiple personality disorder)
Subpersonalities
Alternate personalities
Managing without memory Andy Wray developed dissociative amnesia after witnessing several horrific deaths in his work as a policeman. His disorder is marked by continuous forgetting. Every few days, many of his new memories disappear, leaving him unable to recognize friends, relatives, and events in any detail. To help him get on with his life, he uses countless notebooks and reminder cards like the ones he is looking at here.
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Dissociative Disorders (part 3)
Dissociative amnesia
Inability to recall important information, usually of an upsetting nature, about one’s life
Memory loss much more extensive than normal forgetting and is not caused by physical factors
Often the amnesia episode is directly triggered by a specific upsetting event
Dissociative Disorders (part 4)
Checklist
Dissociative amnesia
Person cannot recall important life-related information, typically traumatic or stressful information. The memory problem is more than simple forgetting.
Leads to significant distress or impairment
Symptoms are not caused by a substance or medical condition
Dissociative identity disorder
Person experiences a disruption to his or her identity, as reflected by at least two separate personality states or experiences of possession
Person repeatedly experiences memory gaps regarding daily events, key personal information, or traumatic events, beyond ordinary forgetting
Leads to significant distress or impairment
Symptoms are not caused by a substance or medical condition
Information from APA, 2013.
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Dissociative Disorders (part 5)
Dissociative amnesia
Localized: Most common type; loss of all memory of events occurring within a limited period
Selective: Loss of memory for some, but not all, events occurring within a period
Generalized: Loss of memory beginning with an event, but extending back in time; may lose sense of identity; may fail to recognize family and friends
Continuous: Forgetting continues into the future; quite rare in cases of dissociative amnesia
All forms of the disorder are similar in that the amnesia interferes mostly with a person’s memory.
Memory for abstract or encyclopedic information usually remains intact.
Clinicians do not known how common dissociative amnesia is, but many cases seem to begin with serious threats to health and safety.
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Dissociative Disorders (part 6)
Dissociative fugue
Extreme version of dissociative amnesia
People not only forget their personal identities and details of their past, but also flee to an entirely different location
May be brief or more severe
For some, fugue is brief—a matter of hours or days—and ends suddenly.
For others, the fugue is more severe: People may travel far from home, take a new name and establish new relationships, and even enter a new line of work; some display new personality characteristics.
When people are found before their fugue has ended, therapists may find it necessary to continually remind them of their own identity.
The majority of people regain most or all of their memories and never have a recurrence.
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PsychWatch: Repressed Childhood Memories or False Memory Syndrome?
Claims of recovery of childhood memories of abuse have declined in recent years
Repressed childhood sexual abuse memories emerge in various settings
Counterargument: Suggestibility
Memories may be flawed illusions or false images formed by a confused mind; created in laboratory
Some people are more prone to false memories
Details of child sexual abuse are often remembered
Dissociative Disorders (part 7)
Dissociative identity disorder (multiple personality disorder)
Two or more distinct personalities (subpersonalities) develop
Each has unique set of memories, behaviors, thoughts, and emotions
Sudden movement from one subpersonality to another (switching) is usually triggered by stress
Women diagnosed three times more often than men
At any given time, one of the subpersonalities dominates the person's functioning.
Usually one of these subpersonalities—called the primary, or host, personality—appears more often than the others.
The transition from one subpersonality to the next (“switching”) is usually sudden and may be dramatic.
Most cases are first diagnosed in late adolescence or early adulthood.
Symptoms generally begin in childhood after episodes of abuse.
Typical onset is before age 5.
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Dissociative Disorders (part 8)
How do subpersonalities interact?
Three kinds of relationships
Mutually amnesic relationships
Mutually cognizant patterns
One-way amnesic relationships
Average number subpersonalities is now thought to be 15 for women and 8 for men; often appear in groups of 2 or 3
The relationships between or among subpersonalities varies from case to case.
Mutually amnesic relationships: Subpersonalities have no awareness of one another.
Mutually cognizant patterns: Each subpersonality is well aware of the rest.
One-way amnesic relationships: Most common pattern; some personalities are aware of others, but the awareness is not mutual. Those who are aware (“co-conscious subpersonalities”) are “quiet observers.”
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Dissociative Disorders (part 9)
How do subpersonalities differ?
Subpersonalities often display dramatically different characteristics
Identifying features
Abilities and preferences
Physiological responses
Identifying features:
Subpersonalities may differ in features as basic as age, sex, race, and family history.
Abilities and preferences:
Although encyclopedic information is not usually affected by dissociative amnesia or fugue, in DID it is often disturbed.
It is not uncommon for different subpersonalities to have different abilities, including being able to drive, speak a foreign language, or play an instrument.
Physiological responses:
Researchers have discovered that subpersonalities may have physiological differences, such as differences in autonomic nervous system activity, blood pressure levels, and allergies.
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Dissociative Disorders (part 10)
How common is DID?
Traditionally, DID was believed to be rare
The number of people diagnosed with the disorder has increased
Although the disorder is still uncommon, thousands of cases have been documented in the United States and Canada alone
Despite changes, many clinicians continue to question the legitimacy of this category
Two factors may account for this increase:
A growing number of clinicians believe that the disorder does exist and are willing to diagnose it.
Diagnostic procedures have become more accurate.
Some researchers argue that many or all cases are iatrogenic—that is, they are unintentionally produced by practitioners.
These arguments are supported by the fact that many cases of DID first come to attention only after a person is already in treatment.
This is not true of all cases, however.
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PsychWatch: Peculiarities of Memory
Many memory peculiarities have been identified
Absentmindedness
Déjà vu
Jamais vu
Tip-of-the-tongue phenomenon
Eidetic images
Memory while under anesthesia
Memory for music
Visual memory
Dissociative Disorders (part 11)
How do theorists explain dissociative amnesia and dissociative identity disorder?
A variety of theories have been proposed to explain dissociative disorders
Older explanations have not received much investigation
Newer viewpoints, which combine cognitive, behavioral, and biological principles, have captured the interest of clinical scientists
Dissociative Disorders (part 12)
How do theorists explain dissociative amnesia and dissociative identity disorder?
Psychodynamic perspective
Dissociative disorders are caused by repression
People fight off anxiety by unconsciously preventing painful memories, thoughts, or impulses from reaching awareness
Dissociative amnesia and fugue are single episodes of massive repression
DID results from a lifetime of excessive repression, motivated by very traumatic childhood events
Dissociative Disorders (part 13)
How do theorists explain dissociative amnesia and dissociative identity disorder?
Psychodynamic perspective
Most of the support for this model is drawn from case histories, which report brutal childhood experiences
Yet only a small fraction of abused children develop this disorder
Dissociative Disorders (part 14)
How do theorists explain dissociative amnesia and dissociative identity disorder?
Cognitive-behavioral perspective
Dissociation grows from normal memory processes and is a response learned through operant conditioning
Behaviorists rely largely on case histories to support their view of dissociative disorders
These explanations fail to explain all aspects of these disorders
Momentary forgetting of trauma leads to a drop in anxiety, which increases the likelihood of future forgetting.
Like psychodynamic theorists, behaviorists see dissociation as escape behavior.
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Dissociative Disorders (part 15)
How do theorists explain dissociative amnesia and dissociative identity disorder?
State-dependent learning
Learning becomes associated with the conditions under which it occurred, so that it is best remembered under the same conditions
People who are prone to develop dissociative disorders have state-to-memory links that are unusually rigid and narrow
Each thought, memory, and skill is tied exclusively to a particular state of arousal, so that a person recalls a given event only when he or she experiences an arousal state almost identical to the state in which the memory was first acquired.
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Dissociative Disorders (part 16)
How do theorists explain dissociative amnesia and dissociative identity disorder?
Self-hypnosis
Parallel between hypnotic amnesia and dissociative disorders
Powerful suggestions to forget
Suggestions put into practice through social and cognitive mechanisms
Although hypnosis can help people remember events that occurred and were forgotten years ago, it can also help people forget facts, events, and their personal identity.
People with dissociative amnesia and fugue often recover on their own.
Only sometimes do their memory problems linger and require treatment.
People with DID usually require treatment to regain their lost memories and develop an integrated personality.
Treatment for dissociative amnesia and fugue tends to be more successful than treatment for DID.
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Dissociative Disorders (part 17)
How do therapists help individuals with dissociative amnesia?
Psychodynamic therapists guide patients to search their unconscious and bring forgotten experiences into consciousness
In hypnotic therapy, patients are hypnotized and guided to recall forgotten events
In drug therapy, intravenous injections of barbiturates are sometimes used to help patients regain lost memories
Often called “truth serums,” the key to the drugs' success is their ability to calm people and free their inhibitions.
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Dissociative Disorders (part 18)
How do therapists help individuals with dissociative identity disorder?
Unlike victims of dissociative amnesia or fugue, people with DID do not typically recover without treatment
Treatment for this pattern, like the disorder itself, is complex and difficult
Dissociative Disorders (part 19)
How do therapists help individuals with dissociative identity disorder?
Therapists usually try to help clients
Recognize fully the nature of their disorder
Recover the gaps in their memory
Integrate their subpersonalities into one functional personality
Unlike victims of dissociative amnesia, people with dissociative identity disorder do not typically recover without treatment.
Therapists usually try to help the clients
Recognize fully the nature of their disorder
Bonding with primary personality
Hypnosis, group, and family therapy
Recover the gaps in their memory
Psychodynamic therapy, hypnotherapy, drug treatment
Integrate their subpersonalities into one functional personality
Fusion, ongoing therapy to maintain a complete personality
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Dissociative Disorders (part 20)
Depersonalization-derealization disorder
DSM-5 categorizes this as a dissociative disorder, but not as one characterized by the memory difficulties found in the other dissociative disorders
Central symptom is persistent and recurrent episodes of depersonalization and/or derealization
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Dissociative Disorders (part 21)
Depersonalization-derealization disorder
Characteristics
Feeling of detachment from own mental processes or body
Observing self from outside
Feeling people or objects are unreal or detached
Transient depersonalization and derealization experiences are relatively common, while depersonalization-derealization disorder is not
Depersonalization experiences by themselves do not indicate a depersonalization disorder.
Transient depersonalization reactions are fairly common.
The symptoms of a depersonalization disorder are persistent or recurrent, cause considerable distress, and interfere with social relationships and job performance.
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