Disorders of Trauma
and Stress
Chapter 5
Stress, Coping, and the Anxiety Response
The state of stress has two components:
Stressor – event that creates demands
Stress response – person’s reactions to the demands
Influenced by how we judge both the events and our capacity to react to
them effectively
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Stress, Coping, and the Anxiety Response
 Extraordinary stress and trauma also play central role in certain
psychological disorders:
 Acute stress disorder
 Posttraumatic stress disorder (PTSD)
 …as well as the Dissociative disorders:
 Dissociative amnesia
 Dissociative identity disorder
 Depersonalization-derealization disorder
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Stress and Arousal:
The Fight-or-Flight Response
 Features of arousal and fear are set in motion by hypothalamus
Two important systems are activated:
Autonomic nervous system (ANS)
Extensive network of nerve fibers that connect CNS to all
other organs
Endocrine system
Network of glands throughout body that release hormones
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Stress and Arousal:
The Fight-or-Flight Response
 There are two pathways, or routes, by which the ANS and
endocrine system produce arousal and fear reactions:
Sympathetic nervous system pathway
Hypothalamic-pituitary-adrenal pathway
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The Autonomic Nervous System
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The Hypothalamic-Pituitary-Adrenal (HPA) Axis
Trauma
 Usually involves actual or threatened serious injury to self or others
 During and immediately after trauma, temporarily experience high
levels of arousal and upset
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Acute and Posttraumatic
Stress Disorders
 Acute stress disorder (ASD)
 Symptoms begin immediately or soon after the traumatic event
and last for less than one month
 Posttraumatic stress disorder (PTSD)
 Symptoms may begin either shortly after the event, or months or
years afterward
 As many as 80% of all cases of acute stress disorder develop
into PTSD
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ACUTE AND POSTRAUMATIC
STRESS DISORDERS
Re-experiencing
 Repeated, distressing
images or thoughts
 Intrusive flashbacks
 Horrifying dreams
Avoidance
 Attempts of avoid
thoughts, feelings
related to the event
 Avoid people, places,
or activities that remind
them of the event
 Numbing of
responsiveness
ACUTE AND POSTRAUMATIC
STRESS DISORDERS
Arousal or anxiety
Dissociative symptoms
 Predicts a worse
prognosis
 Dazed and act
“spaced out”
 Hypervigilance
 Depersonalization
 Restlessness, agitation,
and irritability
 Derealization
 Exaggerated startle
response
 Dissociative amnesia
What Triggers Acute and Posttraumatic Stress
Disorders?
 Can occur at any age and affect all aspects of life
 At least 3.5% of people in the U.S. are affected each year
 7–9% of people in the U.S. are affected sometime during their
lifetime
 Around two-thirds seek treatment at some point
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What Triggers Acute and Posttraumatic Stress
Disorders?
 Ratio of women to men is 2:1
 Low incomes 2x as likely
 Victimization, Combat, Disasters, & Abuse
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Why Do People Develop Acute and
Posttraumatic Stress Disorders?
 Biological and genetic factors
 Traumatic events trigger physical changes in the brain and body that
may lead to severe stress reactions and, in some cases, to stress
disorders
 Some research suggests abnormal especially norepinephrine and
cortisol levels
 Evidence suggests that once a stress disorder sets in, further
biochemical arousal and damage may also occur (especially in the
hippocampus and amygdala)
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Why Do People Develop Acute and
Posttraumatic Stress Disorders?
 Personality factors
 Preexisting high anxiety
 Negative worldview
 A set of positive attitudes (called resiliency or hardiness) protective
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Why Do People Develop Acute and
Posttraumatic Stress Disorders?
 Childhood experiences
 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
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Why Do People Develop Acute and
Posttraumatic Stress Disorders?
 Social support
 People whose social support systems are weak are more likely to
develop a stress disorder after a traumatic event
 Severity of the trauma
 Generally, the more severe the trauma and more direct one’s
exposure to it, greater likelihood of developing stress disorder
Especially risky: Mutilation and severe injury; witnessing the injury or
death of others
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ACUTE AND POSTRAUMATIC
STRESS DISORDERS
 Psychological Factors in ASD and PTSD
 Two-factor theory
Classical conditioning creates fear when the terror of trauma is paired with
the cues associated with it.
Operant conditioning maintains avoidance by reducing fear (negative
reinforcement). Avoidance prevents the extinction of anxiety through
exposure.
How Do Clinicians Treat Acute and
Posttraumatic Stress Disorders?
 About half of all cases of PTSD improve within 6 months; the remainder may
persist for years
 Treatment procedures vary depending on type of trauma
 General goals:
 End lingering stress reactions
 Gain perspective on painful experiences
 Return to constructive living
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How Do Clinicians Treat Acute and
Posttraumatic Stress Disorders?
 Treatment
 Drug therapy
 Anti-anxiety and antidepressant medications are most common
 Behavioral exposure techniques
 Reduce specific symptoms, increase overall adjustment
 Use flooding and relaxation training
 Use eye movement desensitization and reprocessing (EMDR)
 Insight therapy
 Bring out deep-seated feelings, create acceptance, lessen guilt
 Often use couple, family, or group therapy formats;
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Dissociative Disorders
 Although their conditions are also triggered by traumatic events,
individuals do not typically experience the significant arousal,
negative emotions and other symptoms associated with the stress
disorders
Instead, their symptoms are characterized by patterns of
memory loss and identity change
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Dissociative Disorders
The key to our identity – the sense of
who we are and where we fit in our environment – is
memory
In dissociative disorders, one part of the person’s memory
typically seems to be dissociated, or separated, from the
rest
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Amnesia
 Retrograde Amnesia
 Anterograde Amnesia
 Is the amnesia biologically-based or psychogenic?
Organic amnesia usually involves personal and general information; also may
involve anterograde amnesia.
Psychogenic amnesia usually involves only personal information; also may
involve retrograde amnesia.
Dissociative Disorders
 There are several kinds of dissociative disorders, including:
 Dissociative amnesia
 Dissociative fugue
 Dissociative identity disorder (multiple personality disorder)
 Depersonalization-derealization disorder
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Dissociative Amnesia
 People with dissociative amnesia are unable to recall important
information, usually of a stressful nature, about their lives
 The loss of memory is much more extensive than normal
forgetting and is not caused by physical factors
 Often an episode of amnesia is directly triggered by a specific
upsetting event
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Dissociative Amnesia
 Dissociative amnesia may be:
 Localized
 Selective
 Generalized
 Continuous
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Dissociative Fugue
 Persons not only forget their personal identities and details of their
past, but also flee to an entirely different location.
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Dissociative Identity Disorder
A person with dissociative identity disorder develops two
or more distinct personalities, called “subpersonalities”,
each with a unique set of memories, behaviors, thoughts,
and emotions
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Dissociative Identity Disorder
 At any given time, one of sub-personalities dominates person’s
functioning
 Usually one of these sub-personalities – called the primary, or
host, personality – appears more often than others
 Transition from one sub-personality to next (“switching”) is usually
sudden and may be dramatic
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Dissociative Identity Disorder
 How do sub-personalities interact?
 The relationship between or among sub-personalities varies from case to case
 Generally there are three kinds of relationships:
 Mutually amnesic relationships
 Mutually cognizant patterns
 One-way amnesic relationships
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Dissociative Identity Disorder
 Sub-personalities often display dramatically different characteristics, including:
 Identifying features
 Sub-personalities may differ in features as basic as age, sex, race, and
family history
 Abilities and preferences
 It is not uncommon for different subpersonalities to have different
abilities, including being able to drive, speak a foreign language, or
play an instrument
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Dissociative Identity Disorder
Subpersonalities often display dramatically different physiological
responses
Differences in autonomic nervous system activity, blood
pressure levels, and allergies
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Dissociative Identity Disorder
Traditionally, DID was believed to be rare
Some researchers even argue that many or all cases are
iatrogenic; that is, unintentionally produced by practitioners
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Dissociative Identity Disorder
 The number of people diagnosed with the disorder has been increasing
 Although the disorder is still uncommon, thousands of cases have been
documented in the U.S. and Canada alone
 Two factors may account for this increase:
 A growing number of clinicians believe that the disorder does exist and
are willing to diagnose it
 Diagnostic procedures have become more accurate
 Despite changes, many clinicians continue to question the legitimacy of this
category
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Why should you doubt claims that
dissociative identity disorder is common?
Most cases of dissociative disorders are diagnosed by a
handful of ardent advocates.
2. The frequency of the diagnosis of dissociative disorders in
general and DID in particular increased rapidly after
release of the very popular book and movie Sybil.
3. The number of personalities claimed to exist in cases of
DID has grown rapidly, from a handful to 100 or more.
4. Dissociative disorders are rarely diagnosed outside of the
United States and Canada; for example, only one
unequivocal case of DID has been reported in Great
Britain in the last 25 years).
1.
DISSOCIATIVE DISORDERS
Causes of Dissociative Disorders
Psychological Factors in Dissociative Disorders
Little controversy that dissociative amnesia
and fugues can be precipitated by trauma.
Trauma is “suspected” in DID, but much of
the data is retrospective.
The vast majority of trauma victims do not
develop a dissociative disorder.
PSYCHODYNAMIC PERSPECTIVES
 Freud’s model
Topographic model
conscious
preconscious
unconscious
How Do Theorists Explain Dissociative
Amnesia and DID?
 State-dependent learning
 If people learn something when they are in a particular state of mind, they are
likely to remember it best when they are in the same condition
This link between state and recall is called state-dependent learning
This model has been demonstrated with substances and mood and may
be linked to arousal levels
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How Are Dissociative Amnesia and DID
Treated?
 Therapists usually try to help the client by:
 Recognizing the disorder
 Recovering memories
 Integrating the subpersonalities
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