Disorders of Trauma & Stress (1) PDF

01 DISORDERS OF TRAUMA & STRESS Chapter 6 Overview Fear, Anxiety, and Stress – Fight or Flight Acute Stress Disorder & PTSD - How Do They Differ? Triggers for the psychological stress disorders Factors that put people at risk for developing a psychological stress disorder. How Ac...

01 DISORDERS OF TRAUMA & STRESS Chapter 6 Overview Fear, Anxiety, and Stress – Fight or Flight Acute Stress Disorder & PTSD - How Do They Differ? Triggers for the psychological stress disorders Factors that put people at risk for developing a psychological stress disorder. How Acute Stress Disorder & PTSD are Treated Anxiety & Phobias Paper Case Study | Victor Anxiety & Phobias Paper | Character Abnormalities What happens when we become stressed?  The arousal that we experience when confronted by a stressor 03 begins in the hypothalamus.  Copyright © 2021 by Macmillan Learning. All rights reserved Stress and Arousal ▪ 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. ABNORMAL PSYCHOLOGY Ronald J. Comer | Jonathan S. Comer | Eleventh Edition  Copyright © 2021 by Macmillan Learning. All rights reserved Stress and Arousal: The Fight-or-Flight Response (part 3) ▪ Two pathways by which ANS and the endocrine system produce arousal and fear reactions ▪ Sympathetic nervous system pathway ▪ Hypothalamic-pituitary- adrenal pathway ABNORMAL PSYCHOLOGY Ronald J. Comer | Jonathan S. Comer | Eleventh Edition  When we face a dangerous situation, the hypothalamus first excites the sympathetic nervous system, which stimulates key organs either directly, e.g., increasing heart rate, or indirectly, e.g., 05 stimulating the adrenal glands which triggers the release of epinephrine and norepinephrine When the perceived danger passes, the parasympathetic nervous system helps return the bodily processes to normal.  The second pathway is the hypothalamic-pituitary-adrenal (HPA) axis. When we are faced with stressors, the 06 hypothalamus signals the pituitary gland, which releases adrenocorticotropic hormone (ACTH). ACTH signals the outer layer of the adrenal gland, the adrenal cortex, to release corticosteroids—stress hormones such as cortisol—into the bloodstream.  The reactions on display in these two pathways are referred to as the fight-or-flight response. 02 People differ in their particular patterns of autonomic and endocrine functioning and, therefore, in their particular ways of experiencing arousal and fear.  Copyright © 2021 by Macmillan Learning. All rights reserved Fear is a “package” of responses (physical, emotional, and cognitive) ▪ 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 ABNORMAL PSYCHOLOGY Ronald J. Comer | Jonathan S. Comer | Eleventh Edition Trauma During and immediately after trauma, many people become highly aroused, anxious, and depressed. – Trauma is defined as an event in which a person is exposed to actual or threatened death, serious injury, or sexual violation. – In contrast to sources of anxiety, these events would be considered traumatic by most, if not all, individuals.  Copyright © 2021 by Macmillan Learning. All rights reserved Disorders of Trauma and Stress ▪ Stress and psychological disorders ▪ Acute stress disorder ▪ Posttraumatic stress disorder (PTSD) ▪ DSM-5-TR lists these as “Trauma and Stressor-Related Disorders.” ▪ Stress and physical (psychophysiological) disorders ▪ DSM-5-TR lists these under “psychological factors affecting medical condition.” ABNORMAL PSYCHOLOGY Ronald J. Comer | Jonathan S. Comer | Eleventh Edition  Copyright © 2021 by Macmillan Learning. All rights reserved Acute Stress Disorder Acute stress disorder is diagnosed when symptoms begin within 4 weeks of the traumatic event and last for less than 1 month. If symptoms last longer than 4 weeks, the disorder is diagnosed as posttraumatic stress disorder (PTSD). ▪ Symptoms can begin at any time following the event but must last for longer than 1 month ▪ Approximately 25% of individuals do not develop the full syndrome until 6 or more months after the trauma occurred. ▪ At least 50 percent of all cases of acute stress disorder develop into PTSD. ABNORMAL PSYCHOLOGY Ronald J. Comer | Jonathan S. Comer | Eleventh Edition Almost Identical Aside from differences in onset and duration, symptoms of acute stress disorders and PTSD are almost identical. ○ Increased arousal, anxiety, and guilt ○ Re-experiencing the traumatic event (flashbacks, nightmares, recurring intrusive thoughts) 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, ○ Avoidance - avoids discussing the event, 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. avoids activities that remind them of event, tries not to think of event PTSD with Dissociative Symptoms Reduced responsiveness and dissociation Individuals may feel disconnected from others Be unresponsive to stimuli Lose interest and motivation Or experience symptoms of dissociation (psychological separation, feeling dazed), depersonalization (feeling that your conscious state or your body is unreal), and derealization (feeling that your environment is strange or unreal) This group tends to be more impaired and distressed than other trauma survivor DSM-5 Identifies PTSD with dissociative symptoms as a special subtype of this disorder Pattern in seen in approximately 30% of individuals with PTSD It is common in those who experienced repeated abuse or childhood abuse Also seen in response to trauma of combat, sexual violence, and other types of physical abuse Acute Stress Disorder and PTSD These disorders can occur at any age and affect all aspects of life. They affect about 3.5 to 6% of the North American population per year and about 7 to 12% of the population per lifetime. Approximately half of patients seek treatment at some point, but relatively few do so when they first develop the disorder. Approximately 20% attempt suicide. These individuals are at increased risk for other psychological (e.g. depression, anxiety, substance use) and physical (e.g., chronic illness, asthma, heart and liver disease) disorders. Women are twice as likely as men to develop stress disorders; after trauma, 20% of women versus 8% of men develop disorders. People with low income are twice as likely as people with higher incomes to experience one of the stress disorders. Acute and Posttraumatic Stress Disorders After experiencing a trauma, Hispanic Americans, African Americans, and American Indians are all more likely to develop a stress disorder than non-Hispanic white Americans. Studies have shown an increased risk is may be linked to poverty or the discrimination that these minority group members experience. Other researchers suggest that cultural beliefs that view trauma as inevitable and unchangeable account for the heightened risk. Any event can trigger a stress disorder; however, some events are more likely to cause disorders than others. What triggers acute and posttraumatic stress disorders? ○ Combat Shell shock; combat fatigue PTSD ○ Disasters and accidents Recent hurricanes; traffic accidents ○ Victimization Lady Gaga developed PTSD at 19 after sexual assault https://bornthisway.foundation/personal-letter-gaga/ Sexual assault and rape Acute and Posttraumatic Stress Disorders 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% of Vietnam combat veterans suffered acute or posttraumatic stress disorders. An additional 22% had some stress symptoms. Some 10% are still experiencing problems. A similar pattern is currently unfolding among 2.7 million veterans of wars in Afghanistan and Iraq. Acute and Posttraumatic Stress Disorders 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. Triggering Events Disaster Year Location Number Killed Flood 1931 Huang River, China 3,700,000 Tsunami 2004 South Asia 280,000 Earthquake 1976 Tangshan, China 255,000 Heat wave 2003 Europe 35,000 Volcano 1985 Nevado del Ruiz, 23,000 Colombia Hurricane 1998 (Mitch) Central America 18,277 Landslide 1970 Yungay, Peru 17,500 Blizzard 1972 Iran 4,000 Tornado 1989 Saturia, Bangladesh 1,300 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. What triggers acute and posttraumatic stress disorders? ○ Terrorism 9/11 Mass shootings ○ Torture Physical torture Psychological torture Sexual torture Torture through deprivation Terrorism and torture: The experience of terrorism or the threat of terrorism often leads to posttraumatic stress symptoms. Years after the attacks, 42 percent of all adults in the United States and 70 percent of all New York adults report high terrorism fears; 23 percent of all adults in the United States report feeling less safe in their homes. It appears that between 30 and 50% of torture victims develop PTSD. Why do people develop acute and posttraumatic stress disorder? ○ Biological factors ○ Childhood experiences ○ Cognitive factors and coping styles ○ Social support systems ○ Severity and nature of the traumas Biological Factors Biological factors ○ Brain–body stress routes ○ Brain’s stress circuit ○ Inherited predisposition Childhood experiences that increase risk for later PTSD ○ Chronic neglect or abuse ○ Poverty ○ Parental conflict End of a journey? Not necessarily, at least in the psychological realm. This small boat filled with migrants comes ashore at Lesbos, a pastoral Greek island through which a half million refugees — mostly from Syria ○ Catastrophe — have passed on their way to countries throughout Europe. The rate of PTSD among refugees can be as high as 56 percent in some areas of the world, particularly for those who were tortured in their homeland ○ Family members with or whose travels were perilous. psychological disorders Biological Factors Some research suggests abnormal neurotransmitter and hormone activity are the cause (especially norepinephrine and cortisol). The brain’s stress circuit includes such structures as the amygdala, prefrontal cortex, anterior cingulate cortex, insula, and hippocampus, among others. Biological Factors 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 these reactions  Childhood Experiences Researchers have found that certain childhood experiences increase risk for later stress disorders. Risk factors include: https://salud-america.org/4-ways-childhood-trauma-changes-childs-brain-body/ 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 Cognitive Factors and Coping Styles Some studies suggest that people with certain personalities, attitudes, and coping styles are particularly likely to develop stress disorders. Risk factors include: cognitive factors: pre-existing memory impairments intolerance of uncertainty, inflexible coping style, not being able to generate different responses to different stressors (increases risk of PTSD) having a negative worldview weak social support systems including family (feeling loved, valued, or cared for, being treated with dignity and respect increases the likelihood of successful recovery from trauma. A set of positive attitudes (called resiliency or hardiness) are protective against developing stress disorders. The Severity and Nature of the Trauma Generally, the more severe trauma or the more direct one’s exposure to it, the greater likelihood of developing a stress disorder Risk factors also include: ○ Intentionally inflicted trauma ○ Mutilation, severe physical injury, or sexual assault The Severity and Nature of the Trauma (Part 2) ○ Experiencing repeated or multiple traumas has been linked to a severe form of PTSD known as: complex PTSD that includes all four types of symptoms as well as profound disturbances in emotional control, self-concept, and interpersonal relationships.  The Developmental Psychopathology Perspective proposes that stress disorders arise from biological, psychological, and environmental factors. Developmental Psychopathology This model says biological predisposition for overactive stress pathways can be inherited or developed as a consequence of early childhood experiences This leads individuals to be at greater risk for developing a stress disorder if they are exposed to trauma. Developmental Psychopathology A childhood filled with protective factors and manageable stress can reduce the risk of the disorder. Stressors and traumas can sensitize critical brain circuits, making the development of a stress disorder more likely when the individual later experiences trauma. Consistent with the idea of equifinality, stress disorders can occur in the absence of these predisposing factors when the trauma is severe enough. Goals for acute and posttraumatic stress disorders ○ About one-third of all cases of PTSD improve within 12 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 How do clinicians treat acute and posttraumatic stress disorders? ○ Combat veterans Antidepressant drug therapy 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 Small veterans outreach programs Community interventions Psychological debriefing (critical incident stress debriefing) Psychological first aid (PFA) 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 is now standard in PTSD treatment. Virtual reality therapy is becoming more common in treatment of other anxiety disorders and phobias. How do clinicians treat acute snd posttraumatic stress disorder? ○ Couple or family therapy Counseling for spouses and children ○ Group therapy referred to as “Rap groups” earlier Individual counseling ○ Combination of some of the above 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 Widely used for 30 years; empirical evidence has raised questions about its effectiveness Unsupported in research; many mental health professionals move away from outright acceptance Psychological first aid - encourages adaptive functioning; addresses the needs and concerns of victims without encouraging survivors to talk about their feelings Case Study | Victor Read the following case study: Victor is a 27-year-old man who comes to you for help at the urging of his fiancée. He was an infantryman with a local Marine Reserve unit who was honorably discharged in 2014 after serving two tours of duty in Iraq. His fiancé has told him he has “not been the same” since his second tour of duty and it is impacting their relationship. Although he offers few details, upon questioning he reports that he has significant difficulty sleeping, that he “sleeps with one eye open” and, on the occasions when he falls into a deeper sleep, he has nightmares. He endorses experiencing several traumatic events during his second tour, but is unwilling to provide specific details – he tells you he has never spoken with anyone about them and he is not sure he ever will. He spends much of his time alone because he feels irritable and doesn’t want to snap at people. He reports to you that he finds it difficult to perform his duties as a security guard because it is boring and gives him too much time to think. At the same time, he is easily startled by noise and motion and spends excessive time searching for threats that are never confirmed both when on duty and at home. He describes having intrusive memories about his traumatic experiences on a daily basis but he declines to share any details. He also avoids seeing friends from his Reserve unit because seeing them reminds him of experiences that he does not want to remember. 1. What symptoms is Victor exhibiting? 2. What additional questions would you like to ask Victor? 3. What is your provisional diagnosis for Victor? 4. Based on your diagnosis, what kind of treatment plan would you recommend for Victor? What symptoms is Victor exhibiting? Victor is exhibiting the following symptoms: Sleep disturbances: Difficulty falling and staying asleep, sleeping lightly (“with one eye open”), and nightmares. Hypervigilance: Spending excessive time searching for threats, being easily startled by noise and motion. Irritability and social withdrawal: Avoids people to prevent snapping at them and prefers to be alone. Intrusive memories: Experiencing daily intrusive thoughts about traumatic experiences. Avoidance behaviors: Avoiding friends from his Reserve unit and refusing to talk about traumatic events to avoid reminders of the experiences. Diminished interest and difficulty concentrating: Finds his job as a security guard boring and struggles with excessive thinking during downtime. Emotional numbness: Displays reluctance to express emotions or engage with his past experiences. What additional questions would you like to ask Victor? To better understand Victor's situation and develop an appropriate treatment plan, the following questions would be helpful: Can you describe how long these symptoms have been occurring? How have these symptoms impacted your daily functioning and relationship with your fiancée? What strategies have you tried to cope with these feelings and symptoms? Have you ever experienced thoughts of harming yourself or others? Are there any specific triggers (e.g., loud noises, certain environments) that exacerbate your symptoms? How would you describe your mood on a daily basis? Have you experienced feelings of sadness, hopelessness, or worthlessness? Have you used any substances (alcohol, drugs) to cope with your symptoms? Would you be open to discussing some of your experiences during your tours of duty in a therapeutic setting? Do you have a support network besides your fiancée? Are there people you trust or confide in? Have you sought any mental health treatment in the past? What is your provisional diagnosis for Victor? Based on the information provided, Post-Traumatic Stress Disorder (PTSD) (DSM-5 Code: 309.81) is the most likely provisional diagnosis. Victor meets the following criteria for PTSD: Criterion A: Exposure to actual or threatened death, serious injury, or sexual violence (self-reported traumatic experiences during his second tour in Iraq). Criterion B: Presence of intrusion symptoms (intrusive memories and nightmares). Criterion C: Persistent avoidance of stimuli associated with the trauma (avoids discussing traumatic events and avoids friends from his Reserve unit). Criterion D: Negative alterations in cognition and mood (social withdrawal, irritability, emotional numbness). Criterion E: Marked alterations in arousal and reactivity (hypervigilance, exaggerated startle response, and sleep disturbances). Duration: Symptoms have persisted for more than one month (symptoms have been present since his second tour in Iraq). Functional significance: Symptoms interfere with his job performance and relationship. Based on your diagnosis, what kind of treatment plan would you recommend for Victor? The treatment plan for Victor may include the following components: 1. Psychotherapy Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): To help Victor process his traumatic experiences, identify and challenge maladaptive thought patterns, and reduce avoidance behaviors. Prolonged Exposure Therapy (PE): Gradual exposure to trauma-related memories, thoughts, and situations to reduce avoidance and desensitize Victor to his triggers. Eye Movement Desensitization and Reprocessing (EMDR): To process unresolved trauma and reduce the emotional distress associated with traumatic memories. Couples Therapy: To improve communication and strengthen his relationship with his fiancée. 2. Pharmacological Interventions SSRIs or SNRIs: Medications such as sertraline (Zoloft) or venlafaxine (Effexor) can be prescribed to address anxiety, depression, and intrusive thoughts associated with PTSD. Sleep medicine: May be recommended to help with nightmares and sleep disturbances. 3. Lifestyle and Self-Care Strategies Sleep hygiene education: Teach Victor techniques to improve his sleep patterns, such as setting a consistent sleep schedule and avoiding stimulants before bedtime. Mindfulness and relaxation techniques: Introduce practices like meditation, deep breathing, and progressive muscle relaxation to manage hypervigilance and irritability. Physical activity: Encourage regular exercise, which has been shown to improve mood and reduce PTSD symptoms. 4. Peer and Social Support Veterans support groups: Recommend participation in groups for veterans who share similar experiences, such as those offered by the VA or community organizations. Reconnect with trusted friends or family: Gradually encourage Victor to rebuild his social network and reduce isolation. 5. Coordination of Care Collaborate with Victor’s primary care physician or a psychiatrist to monitor progress and address any medical or mental health concerns. Ensure Victor’s fiancée is informed and involved in his care as appropriate to strengthen his support system. Questions, Comments, What’s Next? On Thursday–Dissociative Disorders Case Study: Victor due Thursday, January 30th Work on your Anxiety & Phobias Paper due Sunday, February 2nd. See you Thursday!