Trauma And Dissociation Lecture Notes PDF

Trauma Disorders Geneviève Trudel, PhD Candidate University of Ottawa We will be discussing traumatic events today. A reminder of the student mental health resource guide: https://1in5initiative.ca/wpcontent/uploads/2021/01/Guide-EN-ressourcessante%CC%81-mentale_-Final.pdf Midterm I Average : 76...

Trauma Disorders Geneviève Trudel, PhD Candidate University of Ottawa We will be discussing traumatic events today. A reminder of the student mental health resource guide: https://1in5initiative.ca/wpcontent/uploads/2021/01/Guide-EN-ressourcessante%CC%81-mentale_-Final.pdf Midterm I Average : 76% For questions or to review the midterms please contact Renée. Special Topics class Recap from last lecture • Developmental trauma • Any question, comments, reflections? Brain development • We are not born with a fully developped brain. Early on, our brains start to develop from the bottom up. • The brainstem (the reptilian/primitive brain) develops first. • Allows for basic functions (e.g., breathing, heart rate, sleep). • Threat response system • ”Am I safe?” • Limbic brain develops next • Involved in emotional development, attachment, memory • “Am I loved?” • Cortical brain develops last • Involves rational thinking, learning, inhibiting • “What can I learn from this?" Early experiences also changes the brain • Neuroplasticity: structural and functional changes in response to experiences and environmental influences. • « what firres together, wires together » • Eventually, traumatised children have an overconnectivity in the parts of their brains required for survival and an underconnectivity in the parts of the brain required for cognition. Effects of early trauma on cognition • Chronically traumatized children often experience under-developed cognitive skills. This affects their ability to: • • • • Plan ahead Problem solve Organize themselves Learn from mistakes • Traumatized children are often "stuck" in their brainstem or limbic system. • They expend resources on assessing safety and determining if they can trust adults. • This limits resources for essential "higher brain" skills needed for cognitive functioning. • Other children will become pre-occupied with school and performance as they may see it as a currency for love. (Beacon House Therapeutic Services and Trauma Team) Self-Concept & Identity Development • Self-concept starts to form from the first messages we receive about ourselves from caregivers. • If caregivers send the message that a child is not worth keeping safe, and their cries pushes people away, children’s self-concept will reflect that. • Individuals who have experienced early trauma often develop a deep sense of being ”bad” or “unwanted” and this is reflected in the way they perceive themselves. • It can be hard for these individuals to learn and accept that they are lovable and worth keeping safe. • These individuals develop a poor sense of identity and may struggle to know simple things such as : what they enjoy, what they don’t enjoy, want they want for their future. (Beacon House Therapeutic Services and Trauma Team) What is the ICD-11 • International Classification of Disease for Mortality and Morbidity Statistics • The international standard for systematic recording, reporting, analysis, interpretation and comparison of mortality and morbidity data • https://icd.who.int/browse11/l-m/en What is Complex PTSD • Develops following exposure to an event or series of events of an extremely threatening or horrific nature, that are often prolonged or repetitive from which escape is difficult or impossible (e.g. torture, prolonged domestic violence, repeated childhood sexual or physical abuse). • All diagnostic requirements for PTSD are met. • In addition, Complex PTSD is characterised by severe and persistent • 1) problems in affect regulation; • 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and • 3) difficulties in sustaining relationships and in feeling close to others. These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning. DSM-5 Criteria: Post-Traumatic Stress Disorder A. Exposure to actual or threat death, serious injury, or sexual violence B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred: D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred F. Symptoms have persisted for at least one month G. Symptoms cause significant distress and/or social/occupational dysfunction • Specifiers • With dissociative symptoms (depersonalization/derealization) ICD-11 Criteria: Complex Post-Traumatic Stress Disorder • Exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged, or repetitive events from which escape is difficult or impossible. • Following the traumatic event, the development of all three core elements of PostTraumatic Stress Disorder, lasting for at least several weeks: • Re-experiencing the traumatic event • Deliberate avoidance of reminders likely to produce re-experiencing of the traumatic event(s). • Persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. ICD-11 Criteria: Complex Post-Traumatic Stress Disorder • Severe and pervasive problems in affect regulation. • Persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the stressor. • Persistent difficulties in sustaining relationships and in feeling close to others. The person may consistently avoid, deride or have little interest in relationships and social engagement more generally. Alternatively, there may be occasional intense relationships, but the person has difficulty sustaining them. • The disturbance results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort. Difference between PTSD and cPTSD • CPTSD often involves continuous exposure to a traumatic event whereas PTSD can occur after a single traumatic event. • CPTSD includes alterations in the perception of self • CPSTD is categorized by difficulties in relationships Bottom-up vs Top-down approaches • Bottom-up therapies : therapies that focus on the body and sensory experiences. Addresses physical sensations, emotions, and bodily responses to trauma or stress. • E.g.: Eye Movement Desensitization and Reprocessing (EMDR), mindfulness, sensory • Top-down approaches : therapies that focus on the cognitive and psychological processes. Focuses on thoughts, beliefs, emotions, and conscious awareness. • E.g., CBT, prolonged exposure Examples of strategies Outline • Trauma and stressor related disorders • Dissociative disorders Post-traumatic stress disorder DSM-5 Criteria: Post-Traumatic Stress Disorder A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: • Directly experiencing the traumatic event(s). • Witnessing, in person, the event(s) as it occurred to others. • 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. • 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 details of child abuse). • Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. DSM-5 Criteria: Post-Traumatic Stress Disorder A. Exposure to actual or threat death, serious injury, or sexual violence B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred: D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred F. Symptoms have persisted for at least one month G. Symptoms cause significant distress and/or social/occupational dysfunction • Specifiers • With dissociative symptoms (depersonalization/derealization) Criterion B Criterion C Criterion D Criterion E Criterion B Criterion C Criterion D Criterion E Criterion B Criterion C Criterion D Criterion E Criterion B Criterion C Criterion D Criterion E Assessment for PTSD • The first step of PTSD assessment is determining Criterion A, which can be a challenge • People often do not want (understandably) to discuss trauma • Assessments do not focus on gathering the details of the trauma (that is done in therapy) • Challenges with PTSD assessment • Many different types of traumatic events (e.g. physical violence, accidents, injuries, natural disasters) • What if there are multiple traumatic events? • How do you gather information without asking too many detailed questions? • What if someone describes an event as traumatic, but does not meet the criteria for Criterion A? Prevalence • Most people who experience traumatic events do not develop PTSD • Given the diversity of experiences that qualify as traumatic, it can be hard to conclusively determine risk following a traumatic event • There is evidence that sexual assault is a particular risk factor for PTSD symptoms (32% lifetime prevalence rate for PTSD among survivors) • 8% lifetime prevalence in the general population • Certain occupations have increased risk for PTSD • First responders • Military personnel • Healthcare workers Moral injury • Describes the psycho-spiritual consequences of events that seriously violate one’s core moral beliefs and expectations (e.g. killing or injuring someone) • These are Potentially Morally Injurious Events • Core features: • Guilt • Shame • Inner conflict or sense of loss relating to ones’ identity, spirituality, or sense of meaning • Loss of trust in self, others, institutions and/or transcendent beings Treatment for PTSD • Exposure-based methods (e.g. prolonged exposure) • Gradual exposure to avoided cues • Rewriting the narrative of the traumatic event (e.g. cognitive processing therapy) • Challenging the beliefs that have emerged following the trauma (e.g. “it was my fault” related guilt) • SSRI medications • Eye movement desensitization and reprocessing (EMDR) • Involves moving the eyes quickly while discussing the trauma Debriefing traumatic events immediately after the event can be damaging (and cause PTSD symptoms) Incident debriefing should be done only for those who request it Acute Stress Disorder • Similar criteria to PTSD • Main distinction: can be diagnosed 3 days to 1 month after the traumatic event (for PTSD, symptoms need to be present at least one month after the event) • Was added to DSM-IV so that early symptoms of PTSD could be formally diagnosed and treated Adjustment disorders • Often diagnosed when the Criterion A of PTSD has not been met A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). 1. 2. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following: Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. B. Significant impairment in social, occupational, or other important areas of functioning. 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. Attachment disorders Reactive attachment disorder Excoriation disorder (skinExcoriation disorder (skinpicking) picking) Disinhibited social engagement disorder Symptoms emerge before the age of 5; unable to form health attachments with parental figures, often due to abusive early experiences Dissociative disorders Depersonalization /Derealization Disorder Dissociative amnesia Dissociative Identity Disorder Dissociation: disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior…frequently in the aftermath of trauma (DSM, 2013) Dissociation can be both a symptom (e.g. in PTSD) and a set of distinct mental disorders Derealization: Depersonalization Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted). Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing). Depersonalization/Derealization Disorder A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both B. During the depersonalization or derealization experiences, reality testing remains intact. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures). Dissociative Amnesia A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. • Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The disturbance is not attributable to the physiological effects of a substance or a neurological or other medical condition D. The disturbance is not better explained by another mental disorder Dissociative Amnesia • The 12-month prevalence for dissociative amnesia among adults in a small U.S. community study was 1.8% (DSM) • Specifier of dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information. Jeff Ingram: https://www.youtube.com/watch?v=TdOHs-6Tqdo Hannah Upp: https://www.youtube.com/watch?v=cjo2IQK6prs Dissociative Identity Disorder Dissociative Identity Disorder • Formerly “Multiple Personality Disorder” • Distinct personalities known as “alters” A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensorymotor functioning. These signs and symptoms may be observed by others or reported by the individual. B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. A. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play. E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). What is integration? • Integration : the organization of all the different aspects of our personality • Typically, we integrate our experiences coherently and have a stable sense of who we are • We are always changing, adjusting, adapting, and reorganizing our personality as we learn and experience new things (Fisher, 2014; Boon et al., 20 The basics of dissociation • • • Dissociation is a failure of integration. When we are born, we depend on a caregiver to take care of us. If the caregiver is unable to do so, we may need to depend on alterations in our consciousness for survival. In chronic experiences of trauma, our functional system and defensive system may become disjointed. FUNCTIONAL DEFENSIVE (Fisher, 2014 Disjointed systems • When our functional system becomes disjointed, we develop two parts of the self : 1- « Going on with normal life » part 2- « Trauma-related » part Going on with normal life Traumarelated (Fisher, 2014 Disjointed systems • • • When the traumatic experiences are chronic, the individual may need to develop many trauma-related parts This can the individual feel fragmented in their memories, thoughts, feelings, and behaviors. This is adaptive. However, this leaves parts of the person ‘’stuck’’ in their trauma. Going on with normal life Traumarelated part Traumarelated part Traumarelated part Traumarelated part Traumarelated part (Fisher, 2014 https://www.youtube.com/watch?v=n2atzoaA2NI Clinical characteristics of DID • Exact prevalence is unclear • Estimated average number of alters is 15 • Almost everyone with DID (97%) has experienced significant childhood trauma; 68% reported incest • Limited social support during or after traumatic events • Some researchers argue DID should be a subtype of PTSD • People with DID have been found to be highly suggestible (highly influenced by others or accepts suggestions without question) Only one-third of American psychiatrists confidently believed that DID should be included in DSM. What are some reasons why? • DID patients are highly suggestible and DID symptoms may be reinforced by therapists • Could result in false reporting of childhood trauma • Could lead to the idea of distinct personalities being reinforced • How do you distinguish between an “recovered memory” that was repressed by dissociative amnesia and a fake memory? • How do you conclusively determine a separate personality? • Could they be faking? In lab experiments, 80% of participants (who do not have dissociative symptoms) spontaneously faked DID to get out of a pretend murder charge • In an official position statement on recovered memories, the Canadian Psychiatric Association warned that childhood memories later recovered in adulthood were of questionable reliability and should never be accepted without corroboration The most fascinating disorders are often the rarest, most controversial, and least well understood Next class • Schizophrenia