Chapter 4 Trauma- and Stressor-Related Disorders PDF

8/11/2024 Copyright Notice Do not remove this notice. 1 CHAPTER 4 TRAUMA- AND STRESSOR- RELATED DISORDERS Copyright © 2017 McGraw-Hil...

8/11/2024 Copyright Notice Do not remove this notice. 1 CHAPTER 4 TRAUMA- AND STRESSOR- RELATED DISORDERS Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-2 2 1  8/11/2024 Diagnoses of Anxiety Disorders Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-3 3 Trauma- and Stressor- Related Disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Prolonged Grief Disorder Other Specified Trauma- and Stressor-Related Disorder Unspecified Trauma- and Stressor-Related Disorder Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-4 4 2  8/11/2024 Trauma- and Stressor- Related Disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Prolonged Grief Disorder Other Specified Trauma- and Stressor-Related Disorder Unspecified Trauma- and Stressor-Related Disorder Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-5 5 LEARNING OBJECTIVES 4.1 Describe the current diagnostic criteria for posttraumatic stress disorder (PTSD) 4.2 Identify the prevalence of PTSD and the course of posttraumatic stress responses 4.3 Compare the different models accounting for the development of PTSD 4.4 Understand the components of effective treatments for PTSD and the current challenges in the treatment of PTSD Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-6 6 3  8/11/2024 Trauma- and Stressor- Related Disorders With various disorders, I will try to cover: – General Description (diagnostic criteria, etc.) – Epidemiology – Aetiology (causes) – Treatment Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-7 7 Posttraumatic Stress Disorder PTSD contrasts to most other disorders in that it is a disorder of nonrecovery. Strong emotions, biological reactions, thoughts, and escape-and- avoidance behaviours occur during and soon after the traumatic event. Those who are eventually diagnosed with PTSD do not typically develop greater symptoms over time; rather, they stall out in their recovery. Its one of the few disorders in which researchers and clinicians can pinpoint the genesis of the disorder and can study risk and resilience factors. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-8 8 4  8/11/2024 The Diagnosis of Posttraumatic Stress Disorder (PTSD) Exposure to a traumatic event Re-experiencing symptoms – (e.g., flashbacks) Avoidance symptoms – (e.g., avoidance of thoughts and reminders) Negative changes in cognitions and mood – (e.g., emotional numbing) Marked alterations in arousal – (e.g., hypervigilance) Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-9 9 DSM-5 Diagnostic Criteria - PTSD A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to the details of child abuse). Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-10 10 5  8/11/2024 DSM-5 Diagnostic Criteria - PTSD B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic events. Note: Children older than 6 may express this symptom in repetitive play. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: Children may have frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings.) Note: Children may reenact the event in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-11 11 DSM-5 Diagnostic Criteria - PTSD C. Persistent avoidance of stimuli associated with the traumatic event(s) beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (e.g., people, places, conversations, activities, objects, or situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic events. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-12 12 6  8/11/2024 DSM-5 Diagnostic Criteria - PTSD D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidence by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad”, “No one can be trusted,” “the world is completely dangerous,” “My whole nervous system is permanently ruined. 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-13 13 DSM-5 Diagnostic Criteria - PTSD E. Marked alterations in arousal and reactivity associated with the traumatic event(s) beginning or worsening after the traumatic events occurred, as evidenced by two (or more) of the following: 1. Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects 2. Reckless or self-destructive behaviour 3. Hypervigilance 4. Exaggerated startle response 5. Problems with concentration 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep) Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-14 14 7  8/11/2024 DSM-5 Diagnostic Criteria - PTSD F. Duration of the disturbance (Criteria B, C, D and E) is more than one month. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-15 15 DSM-5 PTSD Subtypes/Specifers PTSD: Preschool subtype For children younger than 6 years old Accounts for differences in PTSD presentation in young children PTSD with prominent dissociative symptoms For individuals who meet full criteria but also experience persistent or frequent experiences of depersonalisation or derealisation Argued to be qualitatively different than PTSD without dissociation PTSD specifier- with delayed expression full criteria not met until 6+ months Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-16 16 8  8/11/2024 Acute Stress Disorder (ASD) Symptoms similar to PTSD Duration varies – Short term reaction – Symptoms occur between 3 days and 1 month after trauma Diagnostic criteria less specific than for PTSD. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-17 17 Acute Stress Disorder A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: (same as PTSD). B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred: (see long list) C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-18 18 9  8/11/2024 Acute Stress Disorder Intrusion Symptoms 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Negative Mood 5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). Dissociative Symptoms 6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing). 7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-19 19 Acute Stress Disorder Avoidance Symptoms 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Arousal Symptoms 10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). 11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects. 12. Hypervigilance. 13. Problems with concentration. 14. Exaggerated startle response. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-20 20 10  8/11/2024 Adjustment Disorders Emotional or behavioural symptoms occurring within 3 months of an identifiable stressor(s) Not persisting for more than 6 months after the stressor, unless it’s an enduring stressor Can be: – with depressed mood, – with anxiety, – with mixed anxiety and depressed mood, – with disturbance of conduct, – or unspecified Can’t meet the criteria for another disorder though Probably the least stigmatised disorder Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-21 21 Adjustment Disorders A. The development of emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). B. These symptoms or behaviours are clinically significant, as evidenced by one or both of the following: (distress and impairment) C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. D. The symptoms do not represent normal bereavement. E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. Specify: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, or unspecified. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-22 22 11  8/11/2024 Prolonged Grief Disorder 1. The death, at least 12 months ago, of a person who was close to the bereaved individual (for children and adolescents, at least 6 months ago). 2. Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) has occurred nearly every day for at least the last month: 1. Intense yearning/longing for the deceased person. 2. Preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death). 3. Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month: 1. Identity disruption (e.g., feeling as though part of oneself has died) since the death. 2. Marked sense of disbelief about the death. 3. Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders). 4. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death. 5. Difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future). 6. Emotional numbness (absence or marked reduction of emotional experience) as a result of the death. 7. Feeling that life is meaningless as a result of the death. 8. Intense loneliness as a result of the death. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-23 23 Prolonged Grief Disorder 4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 5. The duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual’s culture and context. 6. The symptoms are not better explained by another mental disorder, such as major depressive disorder or posttraumatic stress disorder, and are not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-24 24 12  8/11/2024 Trauma- and Stressor- Related Disorders With each disorder, I will try to cover: – General Description (diagnostic criteria, etc.) – Epidemiology – Aetiology (causes) – Treatment Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-25 25 Trauma and PTSD: Prevalence and Epidemiological Factors In large study, approximately 60.7% of men and 51.2% of women had experienced at least one trauma in their lifetime. In comparison with women, men were more likely to report experiencing a physical attack, being threatened with a weapon, being in an accident, or witnessing a trauma. Women were more likely to report rape, molestation, neglect, or physical abuse (Kessler, et al., 1995). Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-26 26 13  8/11/2024 Trauma and PTSD: Prevalence and Epidemiological Factors Approximately 23% of the population is estimated to experience at least one motor vehicle accident (MVA) in their lifetime, and the incidence of PTSD from MVAs is estimated at 12%. These statistics suggest that perhaps the important question to ask is not, “Who develops PTSD?” but rather, “Who fails to recover following a traumatic event?” Less than 7% of the population will have had PTSD at some point in their lifetime (Kessler et al., 2005). Rates of PTSD are significantly higher among groups that are exposed to more trauma (e.g., war veterans) Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-27 27 Anxiety-Related Disorders in Australia Data from: Teesson, Mitchell, Deady, Memedovic, Slade, & Baillie. (2011). Affective and anxiety disorders and their relationship with chronic physical conditions in Australia: findings of the 2007 National Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry, 45, 939-946 Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-28 28 14  8/11/2024 Posttraumatic Stress Disorder Epidemiology – Lifetime prevalence in Australia are between 5 and 10 per cent – Prevalence is similar in children and adults exposed to trauma Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-29 29 Intimate Relationships and PTSD Epidemiological studies indicate that those with PTSD are as likely as those without PTSD to be married, but both men and women with PTSD are substantially more likely to divorce, and divorce multiple times, following onset of the disorder. PTSD is also associated with relationship discord, domestic violence, sexual dysfunction, and mental health problems in the partners of those with PTSD. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-30 30 15  8/11/2024 Comorbidity and PTSD Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-31 31 Posttraumatic Stress Disorder With each disorder, I will try to cover: – General Description (diagnostic criteria, etc.) – Epidemiology – Aetiology (causes) – Treatment Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-32 32 16  8/11/2024 Aetiology of PTSD Genetics Severity and type of trauma Neurobiological – Smaller hippocampal volume linked to PTSD  Disruption of verbal vs. nonverbal memory – Supersensitivity to cortisol Behavioural – Mowrer’s Two-factor model Psychological – Perception of control – Avoidance coping, dissociation, memory suppression Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-33 33 Risk Factors for PTSD Gender Type of Traumatic Event Peritraumatic Dissociation Anger (predicts slower recovery) Prior trauma Negative Beliefs Cognitive Avoidance Social Support (lack of or negative) Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-34 34 17  8/11/2024 Risk Factors for PTSD From Brewin et al. Meta-Analysis Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-35 35 Types of Traumatic Events and PTSD Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-36 36 18  8/11/2024 The Aetiology of Posttraumatic Stress Disorder (PTSD) Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-37 37 The Aetiology of Posttraumatic Stress Disorder (PTSD) Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-38 38 19  8/11/2024 Posttraumatic Stress Disorder With each disorder, I will try to cover: – General Description (diagnostic criteria, etc.) – Epidemiology – Aetiology (causes) – Treatment Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-39 39 The Treatment of PTSD Medication – Particularly selective serotonin reuptake inhibitors (SSRIs) Cognitive-behaviour therapy – Involving psychoeducation, anxiety management, cognitive restructuring, imaginal exposure and in vivo exposure, and relapse prevention Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-40 40 20  8/11/2024 Psychological Treatment of PTSD Exposure to memories and reminders of the original trauma – Either direct (in vivo) or imaginal (for memories) – Treatment may initially increase symptoms – More effective than medication or supportive therapy – Eye-movement desensitization and reprocessing (EMDR) is a controversial variant, but data support its use. Cognitive therapy – Enhance beliefs about coping abilities – Adding CT to exposure may not improve treatment response Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-41 41 The Prevention PTSD Difficult to determine whether early interventions are effective or whether the stress response remits naturally Early interventions use CBT approaches Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-42 42 21  8/11/2024 Current Challenges in Treatment and Prevention High rates of drop out from treatment Need to better prepare patients to tolerate the distress of exposure therapy Potentially augment CBT by enhancing extinction Internet-based approaches are promising Also need to develop community-based treatments Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-43 43 Any Questions? If so, post them online Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 4-44 44 22