trauma_2024.pdf

PSYC30014 PSYCHOPATHOLOGY OF EVERYDAY LIFE TRAUMA AND STRESSOR R E L AT E D DISORDERS PROF LISA PHILLIPS TODAY’S LECTURE AIMS TO… 1 2 3 4 Introduce you to the Develop an understanding Introduce you t...

PSYC30014 PSYCHOPATHOLOGY OF EVERYDAY LIFE TRAUMA AND STRESSOR R E L AT E D DISORDERS PROF LISA PHILLIPS TODAY’S LECTURE AIMS TO… 1 2 3 4 Introduce you to the Develop an understanding Introduce you to some of Introduce you to some of features of the disorders of the key features, risk the contemporary models the psychological factors included in the DSM5 factors and associated for understanding the associated with these section ‘Trauma and features of these development and/or disorders. Stressor Related disorders; maintenance of these Disorders’; disorders; WARNING DSM5: TRAUMA AND STRESSOR RELATED DISORDERS Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Other Specified Trauma- and Stressor-Related Disorder Unspecified Trauma- and Stressor-Related Disorder POSTTRAUMATIC STRESS DISORDER WILFRED OWEN In all my dreams, before my helpless sight, He plunges at me, guttering, choking, drowning. – From Dulce and Decorum Est (1920)  DSM5 PTSD- CRITERION A 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 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.  DSM5 PTSD- CRITERION B B. Presence of one (or more) of the following intrusion symptoms: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. 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).  DSM5 PTSD- CRITERION C 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 (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).  DSM5 PTSD- CRITERION D D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced 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.  DSM5 PTSD- CRITERION D, CONT 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).  DSM5 PTSD- CRITERION E E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).  DSM5 PTSD F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 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. Specify whether With dissociative symptoms Specify if With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).  One of 5 One of 2 Including 2 Two of 6 symptoms symptoms of 7 symptoms symptoms of –ve alterations in cognition/ mood SUBTYPES - dissociative subtype- individual reports experiences of depersonalization or derealization; - delayed expression subtype- full diagnostic criteria are not met until at least 6 months after the trauma  BRACKET CREEP DSM-III-R DSM-IV DSM5 MDD 227 227 227 Specific phobia 1 1 1 Social phobia 1 1 1 Panic 7,814 54,698 23,442 PTSD 84,645 79,794 636,120 MORAL INJURY A significant proportion of soldiers worldwide develop feelings of shame, guilt and/or betrayal and anger as a result of their deployment experience, with estimates ranging from approximately 5 to 25%; “Moral injury” refers to the profound and persistent psychological distress that people may develop when their moral expectations and beliefs are violated by their own or other people’s actions Overlap between PTSD and moral injury – Molendijk et al (2022) DSM5 ACUTE STRESS DISORDER A. Exposure to traumatic event- identical to Criterion A for PTSD B. Presence of nine (or more) of the symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred: 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. DSM5 ACUTE STRESS DISORDER A. Exposure to traumatic event- identical to Criterion A for PTSD B. Presence of nine (or more) of the symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred: 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.  ACUTE STRESS DISORDER: INCIDENCE Recent meta-analysis of road accident survivors; 13 studies comprising 2989 patients; 15.8% of patients met criteria for ASD (using DSM-IV criteria) – Dai et al., 2018 TRAJECTORIES FOLLOWING TRAUMA (1)  a recovery class a resilient class with initial which consistently distress then shows few PTSD gradual remission: symptoms: 65.7% 20.8% TRAJECTORIES FOLLOWING TRAUMA (2) a delayed reaction class with initial a chronic distress low symptom class with levels but consistently high increased PTSD levels:8.9% symptoms over time,: 10.6% Galatzer-Levy, Huang, & Bonanno (2018) RATES OF TRAUMATIC EXPERIENCES 75% of adult population (76% men and 74% of Prevalence of trauma women) experience one higher in MH clinical or more traumatic events populations- up to 80% in their lifetime(Mills et al., individuals. 2011)  TYPES OF TRAUMATIC EXPERIENCES Most common events overall: witnessing someone being badly injured or killed, being involved in a fire or natural disaster and being involved in life-threatening accident (all more likely to have been experienced by men); Men: more likely to have experienced- physical attack, combat being threatened with a weapon, held captive or kidnapped; Women: more likely to have experienced rape, sexual molestation, childhood parental neglect and childhood physical abuse. PTSD EPIDEMIOLOGY Probability of PTSD 12-month developing PTSD after prevalence: a traumatic event: men 8–13% 4.4% (McEvoy et al., women 20–30%. 2011) PTSD- TYPES OF TRAUMA Trauma type % PTSD Rape 8.4% M; 9.2% F Sexual molestation 11.8% M; 5.5% F Combat 4.7% M Life threatening accident 1.5% M; 1.7% F Natural disaster 0.3% M; 1.3% F PANDEMICS AND PTSD Higher levels of psychiatric symptomatology incl depression, anxiety, PTSD and higher levels of substance use than expected by young people since COVID-19 (Canada: Craig et al., 2022; Australia: https://www.theage.com.au/lifestyle/health-and-wellness/urgent- national-priority-pandemic-s-staggering-mental-toll-on-young- australians-20220318-p5a5v0.html); High mental health impact experienced by healthcare workers (Hill et al., 2022) Moral injury experienced by healthcare workers (D’Alessandro et al., 2022)  PTSD- RISK FACTORS Pre trauma factors – Gender- female – Personality- high neuroticism – Age- young – Lower intelligence/lower education – Neuroticism – Unstable family during childhood – Pre-existing mood/anxiety disorder – Family history of mood/anxiety disorder – Biological- attenuated cortisol levels PTSD- RISK FACTORS Trauma-related factors Type of trauma e.g. interpersonal Perceived degree of life threat Predictability and controllability Duration and frequency Peri-traumatic reactions Arousal- HR in acute post trauma phase Dissociation at time of trauma Post trauma factors Level of social support and positive support Validation of the experience Opportunities to ‘process’ the experience PTSD- ASSOCIATED FEATURES Substance Emotional use/abuse lability Impulsive and/or Physical self harming complaints behaviour PTSD + MEMORY 1. Disturbance to the memory of the trauma itself- some people may have remarkable clarity, others report complete amnesia for significant aspects of a traumatic event and uncertainty regarding the sequence of events. 2. Re-living experiences or ‘flashbacks’- may be triggered by recent events/experiences: different to normal autobiographical memory b/c dominated by sensory detail but typically disjointed and fragmented; 3. Generally, individuals with PTSD have more difficulty learning, retaining, and recalling new information, PTSD: DISSOCIATION “a temporary breakdown in.. the relatively continuous, interrelated processes of perceiving the world around us, remembering the past, or having a single identity that links out past with our future” (Brewin & Holmes, 2003); Mild dissociative reactions are common under stress- i.e 96% soldiers undergoing survival training; May impact on capacity to form memory of the traumatic event, to integrate that memory with other memories PTSD: COGNITIVE APPRAISAL AND EMOTION Appraisal of the cause of, responsibility for, and concerns about future implications of trauma can result in negative emotions; PTSD: BELIEFS ABOUT THE WORLD AROUND US General increase in negative beliefs about self, world and other found in trauma victims suffering PTSD cf victims not suffering PTSD; CLASSICAL CONDITIONING FEAR CONDITIONING  COGNITIVE-BEHAVIOURAL MODEL OF PTSD Ehlers & Clark, 2000 Predisposing Factors TRAUMA Trauma memory Negative appraisals (fear conditioning) of trauma and Current threat stress Arousal Intrusions Strong emotions Dysfunctional strategies  COGNITIVE-BEHAVIOURAL MODEL OF PTSD Prior trauma, psych Ehlers hx, poor support, & Clark, 2000 Predisposing Factors TRAUMA Trauma memory Negative appraisals (fear conditioning) of trauma and Current threat stress Arousal Fragmented, Intrusions frozen at worst Strong emotions moment (not contextualized), primed by trauma Dysfunctional reminders to strategies Avoidance, dissociation, create substance abuse conditioned fear response  BARRIERS TO TREATMENT concerns related to stigma, shame and rejection, low mental health literacy, lack of knowledge and treatment-related doubts, fear of negative social consequences, limited resources, time, and expenses. specific trauma-related barriers to mental health service use, especially concerns about re-experiencing the traumatic events. – Kantor et al., 2017 COMPLEX PTSD Associated with chronic and repeated traumas; Includes symptoms of PTSD; BUT ALSO the development of persistent and pervasive impairments in affective, self and relational functioning, including – Emotion Dysregulation (I react intensely to all sorts of things) – Interpersonal dysfunction (My relationships have extreme ups and downs) – Difficulties in self-identity (I feel empty or hollow inside) DIFFERENTIATING PTSD FROM COMPLEX PTSD Cloitre et al (2013) Latent Profile Analysis on assessment data from 302 treatment- seeking individuals with diverse trauma histories, ranging from single events (e.g., 9/11 attacks) to sustained exposures (e.g., childhood or adult physical and/or sexual abuse). CLOITRE ET AL (2013) Cloitre et al., 2014  DSM5: ADJUSTMENT DISORDER 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). B. 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. – 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. E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. DSM5: ADJUSTMENT DISORDER With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant. With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant. With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant. With disturbance of conduct: Disturbance of conduct is predominant. With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant. Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder. ICD-11: ADJUSTMENT DISORDER Essential (Required) Features: A maladaptive reaction to an identifiable psychosocial stressor or multiple stressors (e.g., single stressful event, ongoing psychosocial difficulty or a combination of stressful life situations) that usually emerges within a month of the stressor. Examples include divorce or loss of a relationship, loss of a job, diagnosis of an illness, recent onset of a disability, and conflicts at home or work. The reaction to the stressor is characterized by preoccupation with the stressor or its consequences, including excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its implications. Once the stressor and its consequences have ended, the symptoms resolve within 6 months. Additional Clinical Features: Symptoms of preoccupation may worsen with reminders of the stressor(s), resulting in avoidance of stimuli, thoughts, feelings or discussions associated with the stressor(s) to prevent preoccupation or distress. Additional psychological symptoms of Adjustment Disorder may include depressive or anxiety symptoms as well as impulsive ‘externalizing’ symptoms, particularly increased tobacco, alcohol, or other substance use. Symptoms of Adjustment Disorders usually abate when the stressor is removed, when sufficient support is provided, or when the affected person develops additional coping mechanisms or strategy. ICD-11: ADJUSTMENT DISORDER Essential (Required) Features: A maladaptive reaction to an identifiable psychosocial stressor or multiple stressors (e.g., single stressful event, ongoing psychosocial difficulty or a combination of stressful life situations) that usually emerges within a month of the stressor. Examples include divorce or loss of a relationship, loss of a job, diagnosis of an illness, recent onset of a disability, and conflicts at home or work. The reaction to the stressor is characterized by preoccupation with the stressor or its consequences, including excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its implications. Once the stressor and its consequences have ended, the symptoms resolve within 6 months. Additional Clinical Features: Symptoms of preoccupation may worsen with reminders of the stressor(s), resulting in avoidance of stimuli, thoughts, feelings or discussions associated with the stressor(s) to prevent preoccupation or distress. Additional psychological symptoms of Adjustment Disorder may include depressive or anxiety symptoms as well as impulsive ‘externalizing’ symptoms, particularly increased tobacco, alcohol, or other substance use. Symptoms of Adjustment Disorders usually abate when the stressor is removed, when sufficient support is provided, or when the affected person develops additional coping mechanisms or strategy. DEFINING FEATURES OF PREOCCUPATION Preoccupation contains factual (neutral) thoughts Thoughts in preoccupation are stressor-related Preoccupation is time-consuming Preoccupation is often associated with negative emotions Eberle & Maercker, 2021 ADJUSTMENT DISORDER- WHAT WE KNOW Quite common – almost three times as common as major depression (13.7 vs. 5.1%) in acutely ill medical in-patients (Silverstone et al., 1996) – diagnosed in up to one third of cancer patients experiencing a recurrence (Okamura et al., 2002) – Primary care- rates varying from 1-18% people seen for mental health problems (Casey et al., 1984; Blacker et al., 1988) – Among psychiatric inpatients, 9% of consecutive admissions to an acute public sector unit were diagnosed with adjustment disorder (Koran et al., 2003) ADJUSTMENT DISORDERS- PROBLEMS No standardised diagnostic assessment tool; Has not been included in any of the major epidemiological studies (such as the Epidemiological Catchment Area Study, the National Comorbidity Survey, Aust National Mental Health survey); Medicalises ‘problems of living’? A “wastebasket diagnosis” for those who fail to meet the criteria for other disorders? Comorbidity??? Best practice treatment???? (see O’Donnell et al., 2018) Read review by Bachem and Casey 2018 T R A U M A A N D S T R E S S O R R E L AT E D D I S O R D E R S - SUMMARY Considered together in DSM For a long time, PTSD sufferers because they all preceded by were discriminated against. the experience of a traumatic Activism during and after the or stressful event. But many Vietnam war finally saw PTSD people who experience trauma ‘officially’ recognised as a do not develop one of these mental disorder; disorders. Complex PTSD: associated with Adjustment Disorder: one of chronic and repeated trauma the most frequently diagnosed and includes symptoms of mental disorders, but defined as PTSD AND persistent and a low-threshold or a diagnosis pervasive impairments in ofexclusion. affective, self and relational functioning SIEGFRIED SASSOON "How many a brief bombardment had its long-delayed after-effect in the minds of these survivors, many of whom had looked at their companions and laughed while the inferno did its best to destroy them. Not then was their evil hour, but now; now, in the sweating, suffocation of nightmare, in paralysis of limbs, in the stammering of dislocated speech. Worst of all, in the disintegration of those qualities through which they had been so gallant and selfless and uncomplaining - this, in the finer types of men, was the unspeakable tragedy of shell shock" From Sherston's Progress (1936)