Module 10 Stress Related Disorders 2024 PDF

MODULE 10 Disorders Specifically Related to Stress Overview of Module: ◦What are “stress” and “trauma”? ◦Disorders Specifically Related to Stress ◦ Adjustment Disorder ◦ PTSD ◦ Complex PTSD ◦Resilience and Post-Traumatic Growth Stress and Trauma Stress ◦Initially a term used in physics ◦ the interac...

MODULE 10 Disorders Specifically Related to Stress Overview of Module: ◦What are “stress” and “trauma”? ◦Disorders Specifically Related to Stress ◦ Adjustment Disorder ◦ PTSD ◦ Complex PTSD ◦Resilience and Post-Traumatic Growth Stress and Trauma Stress ◦Initially a term used in physics ◦ the interaction between a force and the resistance to counter that force Stress Hans Selye ◦noticed patients often had common presenting problems, even with different diseases ◦ Fatigue, loss of appetite, loss of interest, weight change ◦described this as “the syndrome of just being sick” Tan, SY, & Yip, A. (2018). Hans Selye (1907-1982): Founder of the stress theory. Singapore medical journal, 59(4), 170–171. https://doi.org/10.11622/smedj.2018043 Stress Hans Selye ◦borrowed the term “stress” to describe the “nonspecific response of the body to any demand” ◦broadened to incorporate psychological as well as physiological stressors Tan, SY, & Yip, A. (2018). Hans Selye (1907-1982): Founder of the stress theory. Singapore medical journal, 59(4), 170–171. https://doi.org/10.11622/smedj.2018043 Stress ◦ 3 phases of the “General Adaptation Syndrome”: ◦ Alarm ◦ akin to “fight or flight” ◦ Resistance ◦ attempt to maintain homeostasis ◦ body remains on alert, less intensely ◦ Exhaustion ◦ resources are depleted ◦ can lead to illness, disease, or death Tan, SY, & Yip, A. (2018). Hans Selye (1907-1982): Founder of the stress theory. Singapore medical journal, 59(4), 170–171. https://doi.org/10.11622/smedj.2018043 Stress ◦a process whereby an individual perceives and responds to events (stressors) that they appraise as overwhelming or threatening to their well-being Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer publishing company. THREAT PRIMARY APPRAISAL SECONDARY APPRAISAL available options, control, efficacy “toxic stress” “trauma” “eustress” increased performance, growth NO THREAT COGNITIVE PROCESSES AS GATEKEEPERS TO STRESS Trauma A single event or repeated events which completely overwhelm the individual’s ability to cope or to integrate the ideas and emotions involved in that experience Public Health Ontario (2020) ACEs: Intervention to prevent and mitigate the impact of ACEs in Canada Trauma ◦It is not the characteristics of an event per se which define it as traumatic ◦Rather, trauma is about the relationship between a given event, the person’s perceptions of that event, and their perceived resources for coping with it Trauma ◦A given event may be experienced as traumatic by a given person at a given time … but not by another person … or by the same person at another time ICD-11 Disorders Specifically Related to Stress ◦ directly related to exposure to a stressful or traumatic event, or a series of such events or adverse experiences ◦ with some disorders, stressors may be within the normal range of life experiences ◦ with other disorders, in nature ◦ disorders are distinguished by the nature, pattern, and duration of symptoms ICD-11 Disorders Specifically Related to Stress ◦Post-traumatic stress disorder ◦Complex post-traumatic stress disorder ◦Prolonged grief disorder ◦Adjustment disorder ◦Reactive attachment disorder ◦Disinhibited social engagement disorder Adjustment Disorder Adjustment Disorder in ICD-11 ◦ maladaptive reaction to an identifiable psychosocial stressor(s) ◦ usually emerges within a month of the stressor ◦ characterized by ◦ preoccupation with the stressor or its consequences, including excessive worry/rumination ◦ failure to adapt to the stressor ◦ causes significant impairment in functioning ◦ resolves in about 6 months Adjustment Disorder ◦a common diagnosis ◦although, by definition, it is timelimited, it is implicated in high-risk, acute suicidality ◦ Shorter elapsed time from first SI to completion ◦ A study of completed male adolescent suicides found about 25% met criteria for AD O’Donnell, M. L., Metcalf, O., Watson, L., Phelps, A., Varker, T., & O’Donnell, M. L. (2018). A Systematic Review of Psychological and Pharmacological Treatments for Adjustment Disorder in Adults. Journal of Traumatic Stress, 31(3), 321–331. https://doi.org/10.1002/jts.22295 Adjustment Disorder ◦understudied ◦ psychotherapy is considered the first-line treatment but there is little evidence to demonstrate efficacy or to identify which types are most useful ◦ the quality of the evidence for positive effects of all psychological and pharmacological treatments has been ranked as “low to very low” O’Donnell, M. L., Metcalf, O., Watson, L., Phelps, A., Varker, T., & O’Donnell, M. L. (2018). A Systematic Review of Psychological and Pharmacological Treatments for Adjustment Disorder in Adults. Journal of Traumatic Stress, 31(3), 321–331. https://doi.org/10.1002/jts.22295 PTSD History of Traumatic Stress as Pathology ◦Emerged initially in the context of “battle fatigue” and “shell shock” ◦ conceptualized as acute and transient reactions to the stress of battle More enduring symptoms were considered “malingering” or “neuroses” Change in conceptualization in the 80’s, fueled in part by the experiences of Vietnam vets PTSD in ICD-11 ◦exposure to an event or situation of an extremely threatening or horrific nature plus ◦a characteristic syndrome lasting for at least several weeks, consisting of all three core elements: 1. Re-experiencing of the events 2. Deliberate avoidance of reminders likely to produce re-experiencing of the traumatic event(s) 3. Persistent perceptions of heightened current threat ◦ Implication that this perception is inaccurate PTSD in ICD-11 ◦ “Re-experiencing” ◦ Examples: ◦ vivid intrusive memories or images ◦ flashbacks ◦ repetitive dreams related to the traumatic event ◦ Typically accompanied by strong or overwhelming emotions and strong physical sensations ◦ Reflecting on or ruminating about events is not enough This Photo by Unknown Author is licensed under CC BY PTSD in ICD-11 ◦ “Avoidance” ◦ external avoidance ◦ of people, conversations, activities, or situations reminiscent of the event(s) ◦ active internal avoidance ◦ of thoughts and memories related to the event This Photo by Unknown Author is licensed under CC BY PTSD in ICD-11 ◦ “Perception of ongoing threat” ◦ Examples: ◦ Enhanced startle reactions ◦ Hostile attribution bias ◦ Guarding oneself against perceived danger ◦ Sitting with back against the wall ◦ Carrying a weapon ◦ Restricting movements and activities This Photo by Unknown Author is licensed under CC BY PTSD Symptom Clusters ◦Consistent with ICD-11 conceptualization, factor analytic studies identify 4 clusters of symptoms: ◦ Intrusive thoughts ◦ Arousal symptoms ◦ Active avoidance ◦ Numbing/passive avoidance Contribute most to functional impairment PTSD Course Onset of symptoms typically occurs within three months of exposure However, onset of symptoms can be delayed can take months to years not unusual in the context of military deployment or natural disaster About ½ of those with PTSD experience full recovery within 3 months of symptom onset TRAUMA EVENT SHORT TERM NO TRAUMA EVENT NO SYMPTOMS LONG TERM NO SYMPTOMS SYMPTOMS PTSD WITH DELAYED ONSET PEOPLE WHO EXPERIENCE A HORRIFIC EVENT SYMPTOMS NO SYMPTOMS RECOVERY ADJUSTMENT DISORDER or ACUTE STRESS REACTION SYMPTOMS PTSD More common with combat and natural disaster PTSD ◦Risk Factors ◦ Gender and sex: ◦ Female:male ratio is 2-3:1 ◦ Both biological factors (hormones) and psychosocial factors (gendered coping behaviours) are hypothesized to play a role ◦ Prior mental illness ◦ Family history of mental illness PTSD ◦Risk Factors ◦ ACEs ◦ Interpersonal trauma (vs disaster or accident trauma) ◦ Low social support ◦ Higher levels of ongoing stress PTSD - Theories Biological Theories During a trauma event the unconditioned response (UR - fear) is triggered by the unconditioned stimulus (US – event), in the context of an acute release of stress hormones. Stress hormones result in an intensified classical conditioning process, pairing UR with CS (environmental cues) FOOD SALIVA Unconditioned stimulus Unconditioned response Environmental cues (Conditioned Stimuli) BELL In the context of a trauma event ASSAULT FEAR Unconditioned stimulus Unconditioned response Environmental cues (Conditioned Stimuli) DARK The UR includes a flood of chemicals which result in strong, onetime learning Cognitive Theories 2 cognitive processes are thought to account for development of PTSD: Maladaptive appraisals / cognitive distortions of the event or the aftermath ◦ “It was my fault” ◦ “People can’t be trusted” Fragmentation of the event memory ◦ Impedes processing and integrating with other positive memories and/or schemas PTSD - Intervention Psychopharmacology ◦Treating general symptoms: ◦ Antidepressants sertraline (Zoloft) - SSRI. paroxetine (Paxil) - SSRI. venlafaxine (Effexor) - SNRI. can take weeks to take effect Psychopharmacology ◦Treating nightmares: ◦ Prazosin ◦ an antihypertensive drug ◦ thought to reduce nightmares by decreasing CNS norepinephrine ◦ takes up to 8 weeks to take effect Psychotherapy PTSD Treatment Comparison Chart from the US Veterans Administration Psychotherapy In Vivo Exposure Cognitive Restructuring Reduce Substance Use Self-regulation Psychoeducation Sleep Tailoring Trauma-Focused Treatment Recognizing the variability in how PTSD affects people’s lives, and the variability in people’s readiness for treatment… It has been recommended that traumafocused intervention be considered a “menu” of treatment components… Which can be split over multiple “episodes of care” Psychotherapy: Components Principle of Change Treatment Strategy Understand trauma reactions Psychoeducation Normalizing symptoms Enhance distress tolerance Training in self-regulation skills Extinguish learning re trauma memory Prolonged imaginal exposure Extinguish learning re situational triggers In vivo exposure Modify automatic thoughts and maladaptive schemas Cognitive restructuring Bryant & Keane in Castonguay and Oltmanns (2016) Psychopathology: From science to clinical practice Psychotherapy: Components Principle of Change Treatment Strategy Manage anger reactions MI re risks and benefits of anger; cognitive restructuring of beliefs driving anger; mindfulness practice to gain distance from angerrelated thoughts Reduce harmful substance use Consider medication; MI; support further behavioural change Reduce sleep disturbance Address nightmares through imaginal exposure; strengthen good sleep habits Reduce rumination on trauma Prolonged imaginal exposure; mindfulness practice; increase distraction techniques Address comorbid depression Cognitive restructuring of depressogenic schemas and beliefs; use event scheduling to increase engagement in positive activities Psychotherapy ◦At the same time… ◦ Current evidence suggests that prolonged exposure is the critical factor in recovery from PTSD ◦ Some (but not all) studies show that cognitive restructuring enhances effects of exposure Universal Care Approaches Trauma Informed Care ◦Universal, primary-care ◦Focus is on reducing iotragenic effects caused through re-traumatization Principles of Trama Informed Care Complex PTSD Complex PTSD ◦ Associated more with chronic exposure or repetitive events where control or escape is not possible ◦ Torture, long term confinement, prolonged IPV, repeated sexual violence, ongoing child abuse Complex PTSD ◦ Thought to prevent development of self-image, self-regulation, attachment, etc. ◦ or to cause foundational injury to those processes if already developed Complex PTSD in ICD-11 ◦ all diagnostic requirements for PTSD are met plus ◦ a severe and persistent pattern of: 1. problems in affect regulation 2. beliefs about oneself as diminished, defeated or worthless, and feelings of shame, guilt or failure related to the traumatic event 3. difficulties in sustaining relationships and in feeling close to others Intervention ◦Marked difficulty with affect regulation may prevent use of typical psychotherapy tchniques ◦Initial treatment focuses on boosting self-regulation and distress tolerance to increase readiness for additional therapies Resilience and Post-Traumatic Growth Resilience a dynamic process of positive adaptation in the context of significant adversity Luthar, Cicchetti, & Becker, 2000, p. 543 Resilience ◦ Exposure to adversity does not guarantee a poor outcome, any more than exposure to a life of ease guarantees wellness ◦ Even among children exposed to multiple stressors, only some develop serious emotional disturbance or persistent behavior problems ◦ Retrospective vs prospective studies Resilience Kauai Longitudinal Study (Werner 2002) ◦ 500 high-risk children born on the island of Kauai in 1955 children ◦ risk factors: poverty, belonging to a disadvantaged cultural group, perinatal trauma, parental mental illness ◦ followed from birth through age 40 KAUAI LONGITUDINAL STUDY children with 4 or more risk factors by age 2 Age 10: Learning or behaviour problems Age 18: Delinquency or MH problems Developed no significant psychological or behavioural problems 1/3 2/3 Resilience Kauai Longitudinal Study (Werner 2002) ◦ The resilient group: ◦ Compared to age peers in the general population Not just OK, but thriving at 40 years: ◦ 0% unemployment ◦ 0% with criminal records ◦ Lower divorce rate ◦ Lower mortality ◦ Fewer chronic illnesses Kauai Longitudinal Study (Werner 2002) The resilient group Not just OK, but thriving at 40 years: ◦ 0% unemployment ◦ 0% with criminal records ◦ Lower divorce rate ◦ Lower mortality ◦ Fewer chronic illnesses Compared to age peers in the general population Resilience More than good luck: They selected or constructed environments that, in turn, reinforced their active, outgoing dispositions and rewarded their competencies. In many ways, they made their own environments and picked their own niches. (Scarr, 1992) Resilience ◦ Early explanations focused on individual traits: ◦ easygoing, engaging temperament ◦ intellectual competence ◦ internal locus of control ◦ positive self-concept ◦ ability to plan ahead ◦ strong religious faith or sense of coherence Resilience ◦ …then broadened to include social contributions: ◦ competent parent, sensitive to the child’s needs ◦ affectionate bonds with alternate caregiver (grandparent, older sibling, teacher, elder) ◦ external support system which rewards competence (church, youth group or school) Connectedness as a Protective Factor Data from Snohomish County Children’s Wellness Centre https://snocochildrenswellnessc oalition.com/index.php/essenti al-learning-2/resiliency/ Post-Traumatic Growth positive psychological change experienced as a result of the struggle with highly challenging life circumstances Tedeschi & Calhoun, 2004 Post-Traumatic Growth ◦Improved life satisfaction, meaning, and/or engagement Post-Traumatic Growth ◦Assessment Tools: ◦ Post-Traumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) ◦ 5 factors: ◦ Personal Strength ◦ New Possibilities ◦ Improved Relationships ◦ Spiritual Growth ◦ Appreciation for Life Post-Traumatic Growth ◦Assessment Tools: ◦ Post-Traumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) ◦ 21 questions, e.g. ◦ I changed my priorities about what is important in life. ◦ I have a greater appreciation for the value of my own life. ◦ I have developed new interests. ◦ I have a greater feeling of self-reliance. ◦ I have a better understanding of spiritual matters. Post-Traumatic Growth Cognitive Theory: ◦The event acts as catalyst to an active process of cognitive re-appraisal of core beliefs ◦Tearing down the old mental scaffolds and rebuilding them in a way which allows the individual to make some meaning of the traumatic event ◦The event itself remains distressing, but the changes resulting from the struggle to cope with it are understood to have some larger benefit Post-Traumatic Growth Relationship to PTSD ◦ PTSD and PTG are not mutually exclusive ◦ Distress is required in order to keep the process of cognitive reappraisal active ◦ PTG does not protect from symptoms of PTSD ◦ Having a meaningful, valuable life is different from being symptom-free Post-Traumatic Growth Necessary conditions: ◦Characteristics of the event ◦ “seismic” – enough to challenge “the assumptive world” Post-Traumatic Growth Necessary conditions: ◦Characteristics of the person ◦ Openness to experience ◦ Openness to feelings ◦ Ability to manage distressing emotions – allows for cognitive engagement ◦ Extraversion Post-Traumatic Growth Necessary conditions: ◦Developmental readiness ◦ Established, coherent set of schemas ◦ Ability to engage in reflection and selfdisclosure ◦Social behaviours ◦ Connection to supportive others ◦ Self-disclosure: sharing a narrative Post-Traumatic Growth Necessary conditions: ◦Cognitive habits ◦ Giving up on old goals and coping strategies in order to invest in new ones ◦ “Positive rumination” ◦ In contrast to “counterfactual rumination” associated with depression and anxiety, which is focused on regret and/or avoidance Jian, Hu, Zong, et al. (2022) Current Psychology. https://doi.org/10.1007/s12 144-021-02515-8 Measures of PTG Relationship between posttraumatic disorder and posttraumatic growth in COVID19 home-confined adolescents An Inverted U-shaped Function n = 2090 Measures of PTSD symptoms NB: data were collected during the first wave of the pandemic Jian, Hu, Zong, et al. (2022) 5 items used to assess exposure to trauma “Objective Exposure” ◦ Is the pandemic serious in your area? ◦ Has a friend or relative been infected with COVID-19? ◦ Do you live in a community in which someone has been infected? ◦ Do you have a friend or relative who has died of COVID-19? “Subjective Exposure” ◦ Have you felt extremely fearful during the pandemic? Jian, Hu, Zong, et al. (2022) PTSD was positively related to objective measures of exposure ◦ a dose-response relationship: the greater the exposure, the stronger the relationship PTG was not related to objective exposure Self-efficacy was positively associated with PTG and moderated the association between PTSD and PTG: ◦ For those with high self-efficacy: PTG became less pronounced as PTSD symptoms increased Self-efficacy: The belief that one can achieve success through one’s own actions Post-Traumatic Growth Health Promotion: ◦Education ◦ Understanding the impact of trauma and the possibility of growth ◦ Re-orientation to present circumstances Post-Traumatic Growth Health Promotion: ◦Supporting effective emotion regulation ◦ Focusing on moments of gratitude, success, future possibility ◦ Mindfulness ◦ Excercize ◦ Acknowledging emotions, making space for them, and letting go of them as they pass Post-Traumatic Growth Health Promotion: ◦Fostering connection to supportive others ◦ Self-help and social support groups ◦ Faith-based communities Post-Traumatic Growth Health Promotion: ◦Fostering disclosure and development of a new, meaningful narrative which incorporates the traumatic event ◦ Reshaping of schemas through shared narrative with the traumatic event as a turning point ◦Providing opportunities for service ◦ Finding work which benefits others Why do people climb Everest!? A Netflix documentary which tells the story of people on and around Everest during the 2015 Nepal earthquake Key Take-Aways