Trauma, Stress, and Related Disorders

Trauma and Stressor-Related Disorders

• DSM-5-TR lists Acute Stress Disorder, Posttraumatic Stress Disorder, Adjustment Disorder, and Prolonged Grief Disorder as trauma and stressor-related disorders.
• "Dissociative Disorders" can also be triggered by trauma:
  • Dissociative Disorder (Multiple Personality Disorder)
  • Dissociative Amnesia
  • Depersonalization/Derealization Disorder

Stress and Arousal: The Fight-or-Flight Response

• Autonomic nervous system (ANS) is an extensive network of nerve fibers that connects the central nervous system to all other organs of the body.
• The autonomic nervous system divides into the sympathetic nervous system and the parasympathetic nervous system.
• When in danger, the sympathetic system activates, and the kidneys release epinephrine (adrenaline) and norepinephrine (noradrenaline).

The HPA Axis

• Endocrine system is a network of glands that release hormones throughout the body.
• The hypothalamic-pituitary-adrenal pathway (HPA) involves the hypothalamus activating the pituitary gland to secrete adrenocorticotropic hormone (ACTH)
• ACTH is the "major stress hormone."
• The adrenal cortex releases stress hormones called corticosteroids, including cortisol, which affect the body's arousal and stress reactions.

Acute and Posttraumatic Stress Disorders

• Acute stress disorder symptoms last at least 3 days, but less than one month; symptoms usually begin shortly after the event.
• Posttraumatic stress disorder (PTSD) symptoms last longer than one month, beginning shortly after the event or months afterward.
• Symptoms of acute stress disorder and PTSD are mostly the same, except for differences in onset and duration of the symptoms.
• The annual prevalence of acute and post-traumatic stress disorders is 3.5%-6%; lifetime prevalence is 7-12%
• Prevalence is higher among women, the LGBTQ+ population, and the BIPOC population.

PTSD Diagnostic Checklist

• A person is exposed to a traumatic event involving death, threatened death, severe injury, or sexual violation, experienced directly or vicariously.
• At least one of the following intrusive symptoms must be experienced:
  • 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)
• Continuous avoidance of trauma-linked stimuli.
• Negative changes in trauma-linked cognitions and moods:
  • Inability to remember key features of the event(s)
  • Experiencing repeated negative emotions
• Conspicuous changes in arousal or reactivity, such as excessive alertness, extreme startle responses, or sleep disturbances.
• Significant distress or impairment, with symptoms lasting more than a month.

Triggers of Stress Disorders

• Shell shock and combat fatigue are triggers of stress disorders in combat scenarios.

• PTSD affects 20% of veterans.

• Disasters, accidents, and illnesses can trigger stress, including:

  • Earthquakes
  • Floods
  • Tornadoes
  • Fires
  • Airplane crashes
  • Serious car accidents
  • Serious medical illnesses

• Victimization can cause stress, including incidents of:

  • Sexual assault
  • Abuse
  • Terrorism
  • Mass shootings
  • Torture, whether physical, psychological, or sexual

Factors in Developing Acute and Posttraumatic Stress Disorders

• Biological factors: Brain-body stress routes, brain's stress circuit, inherited predisposition
• Childhood experiences: Adverse childhood experiences (ACEs)
• Cognitive factors and coping styles:
  • Memory impairments
  • Intolerance of uncertainty
  • Inflexible coping style
  • Low resilience
• Social support systems
• Severity and nature of the traumas
• Complex PTSD

PTSD Treatment

• One-third of PTSD cases improve within 12 months, but the remainder can persist for years.
• Goals of treatment are to end lingering stress reactions, gain perspective on painful experiences, and return to constructive living.

PTSD Treatment Procedures/Therapies

• Antidepressant medication.
• Cognitive-behavioral therapy, including:
  • Cognitive processing therapy (CPT)
  • Mindfulness-based techniques
    • Exposure techniques (use virtual reality)
  • Prolonged exposure
  • Written exposure therapy (WET)
• Eye movement desensitization and reprocessing (EMDR)
• Couple or family therapy
• Group therapy and small veterans outreach programs
• Community interventions
  • Psychological debriefing (Critical Incident Stress Debriefing)
  • Psychological first aid (PFA)

Adjustment Disorder

• Adjustment disorder involves symptoms in response to an identifiable stressor within 3 months of the stressor's onset.
• There is marked distress out of proportion to the stressor, causing significant impairment.
• Once the stressor has ended, symptoms are relieved within 6 months.

Prolonged Grief Disorder

• Prolonged Grief Disorder is different from a common bereavement reaction.
• After 12 months after the death of a loved one, a person shows persistent and severe grief and related symptoms, causing significant impairment.

Dissociative Disorders

• Dissociative disorders are marked by major changes in memory that do not have clear physical causes and are triggered by traumatic events.
• Dissociation when one part of memory or identity becomes separated from other parts.
• A sense of who we are and where we fit in our environment defines identity
• Memory is the key to the sense of identity and the link between our past, present, and future.

Types of Dissociative Disorders

• Dissociative amnesia can include dissociative fugue.
• Dissociative identity disorder is also known as multiple personality disorder.
• Other dissociative disorders include depersonalization-derealization disorder.

Dissociative Amnesia Diagnostic Checklist:

• A person cannot recall important life-related information, typically the traumatic or stressful, going beyond simple forgetting.
• Significant distress or impairment occurs.
• The symptoms were not caused by substance use or a medical condition.
• Dissociative fugue is specified when the person travels to a new location and may assume a new identity while forgetting their past.

Dissociative Amnesia

• It is the inability to recall important information, usually of an upsetting nature, about one's life.
• Memory loss is more extensive than typical forgetting and not caused by physical factors.
• Amnesia may be triggered by a specific upsetting event.
• Memory for abstract or encyclopedic information usually remains intact, as does procedural memory; only the autobiographic memory is impacted.
• The duration of amnesia can range from hours to years.

Forms of Dissociative Amnesia

• Localized: most common form; memory loss of all events occurring within a limited period
• Selective: memory loss for some, but not all, events occurring within a period
• Generalized: memory loss begins with an event but extends back in time; may lose sense of identity and fail to recognize family and friends
• Continuous: forgetting that continues into the future, which is quite rare

Dissociative Fugue

• Dissociative fugue is an extreme version of dissociative amnesia.
• People forget their identities and details of their past while fleeing to an entirely different location.
• The characteristics may be brief or severe.
• A person may display new personality characteristics and more outgoing behaviors.
• The majority of those with dissociative fugue regain most or all memories with no recurrence.

Dissociative Identity Disorder (DID)

• Dissociative identity disorder is also known as multiple personality disorder
• Two or more distinct personalities (subpersonalities or alternate personalities) develop within the individual.
• Each personality has a unique set of memories, behaviors, thoughts, and emotions.
• Sudden movement, called switching, from one subpersonality to another is usually triggered by stress.
• Symptoms typically start in childhood after abuse or trauma.
• Women are diagnosed three times more often than men.

Diagnostic Checklist: Dissociative Identity Disorder

• Person experiences a disruption to their identity, as reflected by at least two separate personality states or experiences of possession.
• A person repeatedly experiences memory gaps regarding daily events, key personal information, or traumatic events, beyond normal forgetting.
• Significant distress or impairment occurs.
• The symptoms are not caused by substance use, a medical condition, or another mental disorder.
• The disturbance is not a normal part of a broadly accepted cultural or religious practice; in children, the symptoms are not better explained by imaginary playmates or other fantasy play.

Subpersonalities Characteristics

• The relationships between subpersonalities include:
  • Mutually amnesic relationships
  • Mutually cognizant patterns
  • One-way amnesic relationships
• The average number of subpersonalities is about 5 to 10, but there can be as many as 100.
• Identifying features (age, gender, race) can differ between subpersonalities.
• Abilities and preferences can differ between subpersonalities.
• Physiological responses, such as blood pressure and brain activity, can be different between subpersonalities.

How Common is DID?

• Traditionally, dissociative identity disorder was relatively uncommon.
• Researchers argue many cases are iatrogenic, unintentionally produced by practitioners.
• DID is also culture-bound, with growing cases in North America, but rare in the U.K., Sweden, Russia, India, and Southeast Asia.
• The number of people diagnosed with the disorder increased in the US in the 1980s and 1990s but decreased in the 21st century, with many clinicians questioning the legitimacy of diagnosis.

Dissociative Disorders Explanation/Cause

• 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.
• Dissociative disorders may also be caused by self-hypnosis.
  • People may hypnotize themselves to forget unpleasant events.
  • Children who experience early abuse or horrifying events may escape the threat by self-hypnosis, mentally separating themselves in order to become another person.

Treating Dissociative Disorders

• Psychodynamic therapists guide patients to search their unconscious and bring forgotten experiences into consciousness.
• Hypnotic therapy guides patients to recall forgotten events through hypnosis.
• Drug therapy: intravenous barbiturates sometimes help patients regain lost memories by calming people to free their inhibitions.
• DID treatment involves recognizing the nature of the disorder, recovering gaps in memory, and integrating subpersonalities into functional personalities in a process known as fusion.

Depersonalization-Derealization Disorder (DPDR)

• Depersonalization-derealization disorder does not cause memory difficulties seen in other dissociative disorders.
• The central symptom is persistent and recurrent episodes of either depersonalization –the sense of self is unreal or detached– and/or derealization –where the world feels unreal or detached
• Occurs in about 1-2% of the population, most often in adolescents and young adults.
• Symptoms are often triggered by extreme fatigue, physical pain, substance use disorder recovery, or intense stress.
• Transient depersonalization and derealization can occur relatively commonly but does not indicate a disorder on its own.

Depersonalization-derealization disorder (DPDR) Checklist:

• Requires the presence of persistent or recurrent experiences of depersonalization, derealization, or both.
  • Depersonalization: involves experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions.
  • Derealization: involves experiences of unreality or detachment with respect to surroundings where individuals, objects, or surroundings are experienced as unreal, foggy, dreamlike, lifeless, or visually distorted.
• Reality testing remains intact during depersonalization or derealization.
• The symptoms cause significant distress or impairment.
• The symptoms are not caused by a substance, a medical condition, or other mental disorder.