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Abnormal Psychology PSY404

Lesson 31

ACUTE AND POSTTRAUMATIC STRESS DISORDERS

What is stress?

· Stress is a process of adjusting to circumstances that disrupt or threaten a person's equilibrium.

· Scientists define stress as any challenging event that requires physiological, cognitive, or behavioral

adaptation.

· Stress is an inevitable, and in some cases a desirable, fact of everyday life.

· Some stressors, however, are so catastrophic and horrifying that they can cause serious

psychological harm.

· Such traumatic stress is defined in DSM-IV-TR as an event that involves actual or threatened

death or serious injury to self or others and creates intense feelings of fear, helplessness, or horror.

1-Acute stress disorder (ASD) occurs within 4 weeks after exposure to traumatic stress and is

characterized by dissociative symptoms, re-experiencing of the event, avoidance of reminders of the

trauma, and marked anxiety or arousal.

2-Posttraumatic stress disorder (PTSD) is also defined by symptoms of re-experiencing, avoidance,

and arousal, but in PTSD the symptoms either are longer lasting or have a delayed onset.

· Dissociation is the disruption of the normally integrated mental processes involved in memory,

consciousness, identity, or perception.

· The DSM-IV-TR classifies PTSD as an anxiety disorder, however, PTSD is of unique importance

and is characterized by mixed symptoms of anxiety and dissociation.

Symptoms of ASD and PTSD

1-People who have been confronted with a traumatic stressor re-experience the event in a number of

different ways.

2-Many people with ASD or PTSD have repeated intrusive flashbacks, sudden memories during

which the trauma is replayed in images or thoughts--often at full emotional intensity.

3-In rare cases, re-experiencing occurs as a dissociative state, and the person feels and acts as if the trauma

actually were recurring in the moment.

4-Marked or persistent avoidance of stimuli associated with the trauma is another symptom of ASD

and PTSD. Trauma victims may attempt to avoid thoughts or feelings related to the event, or they may

avoid people, places, or activities that remind them of the trauma.

5- PTSD, the avoidance also may manifest itself as a general numbing of responsiveness. People suffering

from PTSD often complain that they suffer from "emotional anesthesia"--their feelings seem

dampened or even nonexistent.

6- Despite their general withdrawal from feelings, people, and painful situations, people with ASD and

PTSD also experience increased arousal and anxiety following the trauma, a symptom which predicts a

worse prognosis when it is more severe.

7-A number of people with PTSD or ASD also have an exaggerated startle response, excessive fear reactions

to unexpected stimuli, such as loud noises.

· Symptoms of anxiety and arousal are the reason why traumatic stress disorders are grouped with

the anxiety disorders in DSM-IV-TR.

· Acute stress disorder is characterized by explicit dissociative symptoms.

· Many people become less aware of their surroundings following a traumatic event.

· They report feeling dazed, and they may seem "spaced out" to other people.

8-Other people experience depersonalization, feeling cut off from themselves or their environment.

People with this symptom may report feeling like a robot or as if they were sleepwalking.

9-Derealization is characterized by a marked sense of unreality about yourself or the world around you.

· ASD also may be characterized by features of dissociative amnesia, specifically the inability to recall

important aspects of the traumatic experience.

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DSM-IV-TR lists a sense of numbing or detachment from others as dissociative symptoms that

characterize acute stress disorder.

A very similar symptom is listed as an indicator of avoidance, not dissociation, in the diagnosis of

PTSD.

This discrepancy in diagnostic criteria reflects some of the broader controversy about whether ASD

and PTSD should be classified as dissociative or anxiety disorders.

Diagnosis of ASD and PTSD

· Maladaptive reactions to traumatic stress have long been of interest to the military.

· Historically, most of the military's concern has focused on battle dropout, that is, men who leave

the field of action as a result of what has been called "shell shock" or "combat neurosis."

· During the Vietnam War, however, battle dropout was less frequent than in earlier wars, but

delayed reactions to combat were much more common.

· This change prompted much interest in PTSD, a condition first listed in the DSM in 1980 (DSM-

III).

· The basic diagnostic criteria for PTSD--re-experiencing, avoidance, and arousal--have remained

more or less the same in revisions of the DSM.

· However, two significant changes in the classification of traumatic stress disorders were made with

the publication of DSM-IV in 1994: Acute stress disorder was included as a separate diagnostic

category, and the definition of trauma was altered.

· The diagnostic criteria for ASD and PTSD are essentially the same.

· The two exceptions are that ASD explicitly includes dissociative symptoms and lasts no longer than

4 weeks, whereas PTSD continues for at least 1 month after a trauma or it has a delayed onset.

· Not surprisingly, many people suffer from ASD after experiencing trauma, and the presence of

ASD may predict future PTSD.

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Earlier versions of DSM defined trauma as an event "outside the range of usual human experience.

Even before September 11, however, researchers discovered that, unfortunately, many traumatic

stressors are a common part of human experience in the United States today.

Thus DSM-IV-TR defines trauma as (1) the experience of an event involving actual or threatened

death or serious injury to self or others and (2) a response of intense fear, helplessness, or horror in

reaction to the event.

The psychological effects of exposure to natural or man-made disasters, like September 11 or the

Oklahoma City bombing in 1995 are of great concern.

September 11 also called attention to the trauma experienced by emergency workers.

Frequency of Trauma, PTSD, and ASD

1-The National Comorbidity Survey found that nearly 8 percent of people living in the United States

will experience PTSD at some point in their lives, including about 10 percent of women and 5 percent

of men.

2-Research finds that women are especially likely to develop PTSD as a result of rape, while combat

exposure is a major risk factor for PTSD among men.

· PSTD is also commonly found among crime victims.

· Still, the single most common cause of PTSD is the sudden, unexpected death of a loved one.

· In general, trauma does not occur completely at random.

· The development of PTSD following a trauma is also not random.

· Researchers have found that people who suffer from ASD are more likely to develop PTSD

subsequently.

· The prediction is far from perfect, however, and two caveats bear special scrutiny.

· First, people with subclinical ASD, that is, with symptoms that are not severe or pervasive enough to

meet diagnostic criteria, nevertheless are at greater risk for PTSD than trauma victims with

relatively few psychological symptoms.

· Second, the different symptoms of ASD are not equally good in predicting future PTSD.

· The presence of three symptoms--numbing, depersonalization, and a sense of reliving the

experience--are the best predictors of PTSD.

· Other research shows how the symptoms of PTSD diminish gradually as time passes.

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However, PTSD can be a chronic disorder.

Scientists studying social factors and the risk for PTSD have focused primarily on (1) the nature of

the trauma and the individual's level of exposure to it and (2) the availability of social support

following the trauma.

Victims of trauma are more likely to develop PTSD when the trauma is more intense, life-

threatening, and involves greater exposure.

As with less severe stressors, social support after a trauma can play a crucial role in alleviating long-

term psychological damage.

A lack of social support is thought to have contributed to the high prevalence of PTSD found

among Vietnam veterans.

In an analysis of more than 4,000 twin pairs, researchers found that MZ twins had a higher

concordance rate than DZ twins for experiencing trauma, specifically exposure to combat.

Following exposure to trauma, identical twins also had higher concordance rates for PTSD

symptoms than did fraternal twins.

A very different line of research focuses on the biological consequences of exposure to trauma and

how these consequences may play a role in the maintenance of PTSD.

People with PTSD show alterations in the functioning and perhaps even the structure of the

amygdala and hippocampus, two biological findings consistent, respectively, with the experience of

heightened fear reactivity and intrusive memories.

Other evidence finds that PTSD is associated with increased levels of circulating norepinephrine

and general psychophysiological arousal, for example, an increased resting heart rate.

Together, the pattern of biological findings suggests that the sympathetic nervous system is aroused

and the fear response is sensitized in PTSD.

The heightened reactivity may be due to the failure of the stress response system to shut down.

According to two-factor theory, classical conditioning creates fears when the terror inherent in

trauma is paired with the cues associated with the traumatic event.

Operant conditioning, in turn, maintains the fears.

Specifically, when fear-producing situations are avoided, the avoidance is negatively reinforced by

the reduction of anxiety.

More recent psychological perspectives focus on individual differences in the risk for ASD and

PTSD.

In addition to preexisting mental health problems, research indicates that cognitive factors such as

expectancies, preparedness, and control influence the risk for PTSD following a trauma.

Some theories suggest that dissociation is an unconscious defense that helps victims to cope with

trauma.

However, research indicates that dissociation is associated with more not less PTSD.

Dissociation may not be adaptive, but most theorists agree that victims of trauma must, over time,

find a balance between gradually facing their painful emotions while not being overwhelmed by

them.

Psychologist Edna Foa, a leading PTSD researcher, has highlighted the importance of emotional

processing, which involves facing fear, diminishing its intensity, and coming to some new

understanding about the trauma and its consequences.

Integrating the experience of trauma with broader memories and beliefs involves the task of meaning

making--finding some broader reason or higher value for enduring the trauma.

The combined evidence suggests alternative pathways can lead to ASD and PTSD.

Anyone might develop ASD or PTSD given a critical level of exposure and a trauma of sufficient

intensity.

The development of PTSD results from a combination of factors, including personality

characteristics that predate the trauma, exposure during the trauma, and emotional processing and

social support afterwards.

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Prevention and Treatment of ASD and PTSD

· The potential for preventing PTSD is so important that the federal Emergency Management

Agency, the government agency that deals with natural and manmade disasters, is required to

provide special funding to community mental health centers during disasters.

· Perhaps the most widely used early intervention is critical incident stress debriefing (CISD), a single

1 to 5 hour group meeting offered within 1 to 3 days following a disaster.

· CISD involves several phases where participants share their experiences, reactions, group leaders

offer education, assessment, and referral if necessary.

· Since World War I, interventions with soldiers who drop out of combat have been based on the

three principles of offering (1) immediate treatment in the (2) proximity of the battlefield with the

(3) expectation of return to the front lines upon recovery.

· The trauma of combat and the structure of the military make generalization of these principles to

other traumas difficult, but the goals are logical ones to modify to fit the unique circumstances of

other traumas.

· Few studies of the treatment of ASD have been conducted, a circumstance that is not surprising

given that the diagnosis was developed only recently.

· Nevertheless, some research indicates that structured interventions with ASD can lead to the

prevention of future PTSD.

· Psychotherapists who specialize in PTSD suggest some general principles for the psychological

treatment of the disorder.

· In the order in which they are likely to be addressed in therapy, these include

1) Establishing a trusting therapeutic relationship

2) Providing education about the process of coping with trauma

3) Stress-management training

4) Encouraging the re-experience of the trauma and

5) Integrating the traumatic event into the individual's experience.

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