Trauma-Related Disorders PDF

TRAUMA-RELATED DISORDERS extreme exposure to aversive details of the event(s) other than through media reports Posttraumatic Stress Disorder (PTSD) B. At least 1 of the following intrusion Extreme resp...

TRAUMA-RELATED DISORDERS extreme exposure to aversive details of the event(s) other than through media reports Posttraumatic Stress Disorder (PTSD) B. At least 1 of the following intrusion Extreme response to severe stressor symptoms: – Anxiety, avoidance of stimuli associated with Recurrent, involuntary, and intrusive trauma, emotional numbing distressing memories of the trauma, or in Exposure to a traumatic event that involves children, repetitive play regarding the actual or threatened death or injury trauma themes; – e.g., war, rape, natural disaster Recurrent distressing dreams related to Trauma leads to intense fear or helplessness the event(s) Symptoms present for more than a month Dissociative reactions (e.g., flashbacks) in Women and PTSD which the individual feels or acts as if the – Rape most common type of trauma (Creamer trauma(s) were recurring, or in children, et al., 2001 re-enactment of trauma during play Intense or prolonged distress or Four categories of symptoms: physiological reactivity in response to – Intrusively re-experiencing the traumatic event reminders of the trauma(s) Nightmares, intrusive thoughts, or images – Avoidance of stimuli C. At least 1 of the following avoidance e.g., refuse to walk on street where rape symptoms: occurred Avoids internal reminders of the – Other signs of mood and cognitive changes trauma(s) Memory loss, negative thoughts and emotions, Avoids external reminders of the self-blame, blaming others, withdrawal trauma(s) – Increased arousal and reactivity Irritability, aggressiveness, recklessness or D. At least 2 of the following negative alterations self-destructiveness, insomnia, difficulty in cognitions and mood: concentrating, hypervigilance, exaggerated Inability to remember an important startle response aspect of the trauma(s) Tends to be chronic Persistent and exaggerated negative Higher risk of suicide and self-injuries, beliefs or expectations about one’s self, illness others, or the world DSM-5 Criteria for Posttraumatic Stress Persistently excessive blame of self or Disorder others about the trauma(s) A. The person was exposed to actual or Persistently negative emotional state, or threatened death, serious injury, or sexual in children younger than 7, more violence, in one or more of the following ways: frequent negative emotions experiencing the event personally, witnessing the Markedly diminished interest or event in person, learning that a violent or participation in significant activities accidental death or threat of death occurred to a Feeling of detachment or estrangement close other, or experiencing repeated or from others, or in children younger than 7, social withdrawal  Persistent inability to experience positive the traumatic event, or in children, repetitive play emotion involving aspects of the traumatic event E. At least 2 of the following alterations in arousal Recurrent distressing dreams related to and reactivity: the traumatic event Irritable or aggressive behavior Dissociative reactions (e.g., flashbacks) Reckless or self-destructive behavior in which the individual feels or acts as if Hypervigilance the traumatic event were recurring, or in Exaggerated startle response children, re-enactment of trauma during Problems with concentration play Sleep disturbance Intense or prolonged psychological distress or physiological reactivity at F. The symptoms began or worsened after the exposure to reminders of the traumatic trauma(s) and continued for at least one month event Persistent inability to experience positive G. Among children younger than 7, diagnosis events requires criteria A, B, E, and F, but only 1 Altered sense of the reality of one’s symptom from either category C or D. surroundings or oneself (e.g., seeing oneself from another’s perspective, Acute Stress Disorder (ASD) being in a daze) Symptoms similar to PTSD Inability to remember an important aspect of Duration shorter the traumatic – Symptoms occur between 3 days and 1 event month after trauma Avoids internal reminders of the trauma(s) As many as 90% of rape victims experience ASD Avoids external reminders of the trauma(s) ASD predicts higher risk of PTSD within 2 Sleep disturbance years. Hypervigilance Irritable or aggressive behavior DSM-5 Criteria for Acute Stress Disorder Exaggerated startle response A. Exposure to actual or threatened death, serious Agitation or restlesssness injury, or sexual violation, in one or more of the Problems with concentration following ways: experiencing the event personally, witnessing the event, learning that a violent or Treatment of PTSD accidental death or threat of death Medications (SSRIs) occurred to a close other, or experiencing – Relapse common if medication is stopped repeated or extreme exposure to aversive details of Exposure to memories and reminders of the event(s) other than through media exposure the original trauma – Either direct (in vivo) or imaginal B. At least 8 of the following symptoms began or Virtual reality (VR) effective worsened since the trauma and lasted 3 to 31 – More effective than medication or supportive days: therapy Recurrent, involuntary, and intrusive – Treatment can be difficult at first distressing memories of Possible increase in symptomatology  Cognitive therapy Obsessions are defined by – Enhance beliefs about coping abilities - recurrent, intrusive, persistent, unwanted – Adding CT to exposure does not improve thoughts, urges, or treatment response images Treatment of ASD may prevent PTSD - the person tries to ignore, suppress, or neutralize – Shows benefits even 5 years after the traumatic the thoughts, event urges, or images Compulsions are defined by Obsessive-Compulsive and Related Disorders - Repetitive behaviors or thoughts that the person feels compelled to perform to prevent distress or a People with obsessive-compulsive disorder dreaded event (OCD) have intrusive, unwanted thoughts and - The person feels driven to perform the repetitive feel pressure to engage in rituals to avoid behaviors or thoughts in response to obsessions overwhelming anxiety or according to rigid rules The obsessions or compulsions are time Obsessions consuming (e.g., at least 1 hour per day) or cause Intrusive, persistent, and clinically significant distress or impairment. uncontrollable thoughts or urges Interfere with normal activities Obsessive-compulsive disorder has these Often experienced as irrational common symptom patterns: Most common: Contamination – this common obsessive Contamination, sexual and pattern is followed by washing or accompanied by aggressive impulses, body problems, compulsive avoidance of the presumably religious, symmetry and/or order contaminated object; the feared object is often hard to avoid (germs, dust); people may literally Compulsions rub the skin off their hands by excessive washing – Impulse to repeat certain behaviors or or be unable to leave the house for fear of germs mental acts to avoid distress - although anxiety is the most common e.g., cleaning, counting, touching, emotional response to the feared object, obsessive checking shame and disgust are also common; – Extremely difficult to resist the impulse contamination is also believed to be passed on – May involve elaborate behavioral rituals from person to person or object to object. – Compulsive gambling, eating, etc. NOT considered compulsions, because they SYMPTOM PATTERNS IN OCD are pleasurable Pathological Doubt – this obsessive doubt is Compulsions only server reduce anxiety, often followed by a compulsion of checking not give pleasure - often implies some danger of violence (e.g., forgetting to turn off the stove, not lacking the DSM-5 Criteria for Obsessive-Compulsive door) Disorder - checking may into involve multiple trips back Obsessions or compulsions into the house (to check the stove, for example) - patients have an obsessional self-doubt and - related to pathological doubt always feel guilty about having forgotten or committed something. Body Dysmorphic Disorder Intrusive Thoughts – there are intrusive People with body dysmorphic disorder (BDD) obsessional thoughts, not necessarily experience persistent and severe thoughts accompanied by a compulsion that they have a flawed appearance - usually repetitive thoughts of a sexual or – Perceive themselves to be ugly or “monstrous” aggressive act that is reprehensible to the person – Women focus on: skin, hips, breasts, legs - patients obsessed with thoughts of aggressive or – Men focus on: height, penis size, body hair, sexual acts may even report themselves to police muscularity or confess to a priest – Body part of focus can differ by culture Other symptom patterns include symmetry or precision or order, which can lead to a DSM-5 Criteria for Body Dysmorphic compulsion of slowness Disorder (e.g., eating, combing one’s hair) and religious Preoccupation with one or more perceived obsessions defects in appearance The person has performed repetitive behaviors Another way to categorize obsessions or mental acts (e.g., mirror checking, seeking is based on the forms they take: reassurance, or excessive grooming) in response to Obsessional ideas – thoughts that repeatedly the appearance concerns intrude into consciousness (words, phrases, Preoccupation is not restricted to concerns rhymes) and interfere with the normal train of about weight or body fat thought, and causing distress to the person; thoughts are obscene, blasphemous, nonsensical Hoarding Disorder - characterized by Obsessional convictions – notions that are tendencies to acquire an excessive often based on the magical formula of “thought = number of objects and extreme act” difficulties in ridding oneself of those (e.g., thinking ill thoughts about my brother will objects. cause him to die); unlike delusions, obsessional beliefs are characterized by ambivalence (i.e., one DSM-5 Criteria for Hoarding Disorder is sure but is also not sure) Obsessional images – vividly imagined scenes, Persistent difficulty discarding or parting with often of a violent, sexual or disgusting nature possessions, (e.g., images of a child being killed, cars colliding, regardless of their actual value decapitation, torture, etc.) that reportedly come Perceived need to save items to mind Distress associated with discarding Obsessional rumination – prolonged, The symptoms result in the accumulation of a inconclusive thinking about a subject to the large number of possessions that clutter active exclusion of other interests; subject is often living spaces to the extent that their intended use metaphysical or religious in nature is compromised unless others intervene - indecisiveness is very common (“What should I wear?”  Hair-pulling disorder (trichotillomania) - Mood Disorders history of pulling out hair, resulting in noticeable hair loss. Major Depressive Disorder Skin-picking (excoriation) disorder - recurrent picking at scabs or places on their skin, Sad mood OR loss of interest or pleasure creating significant lesions that often become (anhedonia) infected and cause scars. Symptoms are present nearly every day, most of the day, for at least 2 weeks Trichotillomania and skin-picking Symptoms are distinct and more severe than a disorder - tend to be preceded by an normative response to significant loss increasing sense of tension, and may lead to gratification, pleasure, or a sense of PLUS four of the following symptoms: relief when the hair has been pulled, or Sleeping too much or too little when the skin or scab has been picked Psychomotor retardation or agitation Poor appetite and weight loss, or increased Cognitive behavioral risk factors for appetite and weight gain hoarding include the ff.: Loss of energy - poor organizational abilities Feelings of worthlessness or excessive guilt - unusual beliefs about the importance of Difficulty concentrating, thinking, or making possessions - responsibility for those possessions, decisions and avoidance behaviors Recurrent thoughts of death or suicide Episodic Treatment of the Obsessive-Compulsive and Symptoms tend to dissipate over time Related Disorders Recurrent Once depression occurs, future Medications episodes likely – SSRIs (serotonin reuptake inhibitors) Average number of episodes is 4 – Tricyclic antidepressants: Anafranil Subclinical depression (clomipramine) Sadness plus 3 other symptoms for 10 Exposure plus response prevention (ERP) days – Not performing the ritual exposes the person to Significant impairments in functioning the full force of even though full diagnostic criteria are the anxiety provoked by the stimulus not met – The exposure results in the extinction of the conditioned Persistent Depressive Disorder response (the anxiety) Depressed mood for at least 2 years; 1 Cognitive therapy year for children/adolescents – Challenge beliefs about anticipated PLUS 2 other symptoms: consequences of not Poor appetite or overeating engaging in compulsions Sleeping too much or too little Usually also involves exposure Poor self-esteem  Trouble concentrating or making decisions 12 months and do not clear for more than 3 Feelings of hopelessness months at a time. Symptoms do not clear for more than 2 Temper outbursts and negative mood are months at a time present in at least two settings (at home, Bipolar disorders are not present at school, or with peers) and are severe in at least one setting. Premenstrual Dysphoric Disorder Onset before age 10. In most menstrual cycles during the past year, at There has never been a distinct period least five of the following symptoms were present lasting more than 1 day during which in the final week before menses and improved elevated mood and at least three other within a few days of menses onset: manic symptoms were present. – Affective lability The behaviors do not occur exclusively – Irritability during the course of major depressive – Depressed mood, hopelessness, or disorder and are not better accounted for self-deprecating thoughts by another mental disorder. – Anxiety This diagnosis cannot coexist with – Diminished interest in usual activities oppositional defiant disorder, attention- – Difficulty concentrating deficit/hyperactivity disorder, intermittent – Lack of energy explosive disorder, or bipolar disorder. – Changes in appetite, overeating, or food craving Bipolar Disorders – Sleeping too much or too little Three forms: – Subjective sense of being Bipolar I, Bipolar II, and Cyclothymia overwhelmed or out of control Mania defining feature of each – Physical symptoms such as breast Differentiated by severity and duration of mania tenderness or swelling, joint or muscle pain, or Usually involve episodes of depression bloating alternating with mania Depressive episode required for Bipolar II, but Disruptive Mood Dysregulation Disorder not Bipolar I Severe recurrent temper outbursts, including verbal or behavioral Mania expressions of temper that are out of State of intense elation or irritability proportion in intensity or duration to Hypomania (hypo = “under”; hyper = “above”) the provocation. Symptoms of mania but less intense Temper outbursts are inconsistent with Does not involve significant impairment, mania developmental level. does The temper outbursts tend to occur at least three times per week. DSM-5 Criteria for Manic and Hypomanic Negative mood between temper Episodes outbursts most days. Distinctly elevated or irritable mood for These symptoms have been present for most of the day nearly every day at least Abnormally increased activity and energy  At least three of the following are Symptoms do not clear for more than 2 noticeably changed from baseline (four if mood is months at a time irritable): Symptoms cause significant distress or Increase in goal-directed activity or impairment psychomotor agitation Unusual talkativeness; rapid speech SUBTYPESOF MAJOR DEPRESSIVE Flight of ideas or subjective impression that EPISODES (MDEs) thoughts are racing Decreased need for sleep Anxious distress, Mixed features - Increased self-esteem; belief that one has special prominent anxiety symptoms ; presence of at talents, powers, or abilities least three manic /hypomanic symptoms, but Distractibility; attention easily diverted does not meet criteria for a manic episode Excessive involvement in activities that are Melancholic features - Inability to likely to have undesirable consequences, such experience pleasure, distinct depressed mood, as reckless spending, sexual behavior, or depression regularly worse in the morning, early driving morning awakening, marked psychomotor retardation or agitation, significant anorexia or For a Manic Episode: weight loss, excessive guilt Symptoms last for 1 week or require Psychotic features - presence of mood- hospitalization or include psychosis congruent or mood-incongruent delusions or Symptoms cause significant distress hallucinations or functional impairment Catatonic features - catatonic behaviors; not actively relating to environment, mutism, For a Hypomanic Episode: posturing, agitation, mimicking others’ speech or Symptoms last at least 4 days movements. Clear changes in functioning that are observable Atypical features - positive mood reactions to to others, but impairment is not marked some events, significant weight gain or increase in No psychotic symptoms are present appetite, hypersomnia, heavy laden feelings in arms or legs, long-standing pattern of sensibility Bipolar I to interpersonal rejection Atleast one episode or mania Seasonal pattern – history of at least two years Bipolar II in which major depressive episodes occur during At least one major depressive episode with at one season of the year (usually the winter) and least one episode of hypomania remit when the season is over Cyclothymic disorder (cyclothymia) Peripartum onset (formerly postpartum Milder, chronic form of bipolar disorder onset) - onset of major depressive episode Lasts at least 2 years in adults, 1 year in during pregnancy or in the 4 weeks following children/adolescents delivery. Numerous periods with hypomanic and depressive symptoms Psychological Treatment of Mood Disorders Does not meet criteria for mania or major Interpersonal psychotherapy (IPT) depressive episode – Short-term psychodynamic therapy – Focus on current relationships oneself Cognitive therapy Suicide: death from deliberate self-injury – Monitor and identify automatic thoughts Non-suicidal self-injury: behaviors intended to Replace negative thoughts with more neutral or injure oneself without intent to kill oneself positive thoughts Mindfulness-based cognitive therapy (MBCT) TYPES OF SUICIDE – Strategies, including meditation, to prevent Egoistic Suicide - absencce of social relapse integration. Behavioral activation (BA) therapy Altruistic Suicide - sacrifice individual – Increase participation in positively reinforcing life to to fulfill some obligation for the activities to disrupt group. spiral of depression, withdrawal, and avoidance Anomic Suicide - lack of social Behavioral couples therapy regulation that occurs during high lovels – Enhance communication and satisfaction of stress and frustration. Fatalistic Suicide - indiiduals are placed Psychological treatment of bipolar disorder under extreme rules or high expectations. – Psychoeducational approaches Provide information about symptoms, course, Preventing Suicide triggers, and treatments Talk about suicide openly and – Family-focused treatment (FFT) matter-of-factly Educate family about disorder, enhance family Most people are ambivalent about their communication, improve problem solving suicidal intentions Treat the associated mental disorder Biological Treatment of Mood Disorders Treat suicidality directly Electroconvulsive therapy (ECT) Suicide prevention centers – Reserved for treatment non-responders – Induce brain seizure and momentary DISSOCIATIVE DISORDERS AND unconsciousness RELATED DISORDERS Unilateral ECT – Side effects Dissociative Disorders Memory loss – ECT more effective than medications Dissociation Unclear how ECT works Some aspect of cognition or experience becomes Transcranial Magnetic Stimulation for inaccessible to consciousness Depression (rTMS) Avoidance response – Electormagnetic coil placed against scalp Some types of dissociation are harmless and – For those that fail to respond to first common (e.g., losing track of time) antidepressent Sudden disruption in the continuity of: Key Terms in the Study of Suicidality Consciousness Suicide ideation: thoughts of killing oneself Emotions Suicide attempt: behavior intended to kill Motivation  Memory Identity How does memory work under stress? – Psychodynamic Traumatic events are repressed – Cognitive Extreme stress usually enhances rather than impairs memory – Interference memory formation Not accessible to awareness later Memory Deficits and Dissociation Distinguishing other causes of memory loss from dissociation: – Dementia Memory fails slowly over time Is not linked to stress Accompanied by other cognitive deficits –Inability to learn new information – Memory loss after a brain injury – Substance abuse DSM-5 Criteria: Dissociative Amnesia Inability to remember important personal information, usually of a traumatic or stressful nature, that is too extensive to be ordinary forgetfulness The amnesia is not explained by substances, or by other medical or psychological conditions Specify dissociative fugue subtype if: – the amnesia includes inability to recall one’s past, confusion about identity, or assumption of a new identity, and – sudden, unexpected travel away from home or work Dissociative Amnesia: Dissociative Fugue – Rarely diagnosed until adulthood Subtype More common in women than men Amnesia and flight and new identity Often comorbid with: – Latin fugere, “to flee” – PTSD, major depression, somatic symptoms Sudden, unexpected travel with inability to Has no relation to schizophrenia recall one’s past – No thought disorders or behavioral – Assume new identity disorganization May involve new name, job, personality characteristics Treatment of Dissociative Identity Disorder – More often of brief duration (DID) – Remits spontaneously Most treatments involve: DSM-5 Criteria for Dissociative Identity Empathic and supportive therapist Disorder (DID) Integration of alters into one fully functioning Disruption of identity characterized by two individual or more distinct personality states (alters) or Improvement of coping skills an experience of possession, as evidenced by discontinuities in sense of self as reflected in Psychodynamic approach adds: altered cognition, behavior, affect, perceptions, Overcome repression consciousness, memories, or sensory-motor Use of hypnosis functioning. This disruption may be observed by Age regression others or reported by the patient Can actually worsen symptoms Recurrent gaps in recalling events or important personal information that are beyond ordinary SOMATIC SYMPTOM-RELATED forgetting DISORDERS Symptoms are not part of a broadly accepted cultural or religious practice Somatic Symptom Disorders Symptoms are not due to drugs or a medical Excessive concerns about physical symptoms or condition health In children, symptoms are not better explained – ‘Soma’ means body by an imaginary playmate or by fantasy play. Etiology of Somatic Symptoms Disorders: Dissociative Identity Disorder (DID) Cognitive Behavioral Factors Two or more distinct and fully developed personalities (alters) Two important cognitive variables: – Each has unique modes of being, thinking, – Attention to bodily sensations feeling, acting, memories, and relationships Automatic focus on physical health – Primary alter may be unaware of existence of cues other alters – Attributions (interpretation) of those Most severe of dissociative disorders sensations – Recovery may be less complete Overreact with overly negative Typical onset in childhood interpretations  distress or functional impairment or warrant Two important consequences: medical evaluation. – Sick role limits healthy life alternatives – Help-seeking behaviors reinforced by attention Conversion Disorder or sympathy. Sensory or motor function impaired but no known neurological cause – Vision impairment or tunnel vision – Partial or complete paralysis of arms or legs – Seizures or coordination problems – Aphonia Whispered speech – Anosmia Loss of smell Hippocrates – Believed disorder only occurred in women – Attributed it to a wandering uterus Originally known as hysteria – Greek word for uterus DSM-5 Criteria for Illness Anxiety Disorder Freud – Coined term conversion Preoccupation with and high level of – Anxiety and conflict converted into physical anxiety about having or acquiring a symptoms serious disease – Famous case of Anna O. Excessive behaviors (e.g., checking for signs of illness, seeking reassurance) or Etiology of Conversion Disorder: maladaptive avoidance (e.g., avoiding Psychodynamic Perspective medical care) Unconscious psychological factor cause No more than mild somatic symptoms Blindsight are present – Not consciously aware of visual input Not explained by other psychological – Failure to be explicitly aware of sensory disorders information Preoccupation lasts at least 6 months DSM-5 Criteria: Factitious Disorder DSM-5 Criteria for Conversion Disorder Fabrication or induction of physical or psychological symptoms, injury, or One or more symptoms affecting voluntary disease motor or sensory function Deceptive behavior is present in the The symptoms are incompatible with absence of obvious external rewards recognized medical disorders Behavior is not explained by another Symptoms cause significant psychological disorder. In Factitious Disorder Imposed on Self - the person presents himself or herself to others as ill, impaired, or injured In 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 MALINGERING Malingering is NOT considered a mental disorder or an illness Malingering individuals fully and deliberately fake or exaggerate illness with the conscious intent to deceive others The reasons for faking illness (e.g., monetary and legal concerns) can be understood by examining the circumstances affecting these individuals rather than their psychological constitutions Individuals are often evasive and uncooperative on examination, and a marked discrepancy appears between their claimed disability and the physical findings Because malingering is not an illness, it has no medical or psychiatric treatment Treatment of Somatic Symptoms and Related Disorders Few controlled treatment outcome studies Cognitive Behavioral Treatment – Identify and change triggering emotions – Change cognitions about symptoms – Replace sick role behaviors with more appropriate social interactions Antidepressants – Tofranil Effective even at low dosages that do not alleviate depressive symptoms