Lecture 5

1. Lecture 5 Stress-related disorders and DID Richard A. Davis Prepared by: Danny Lam Modified by:

2. Lecture outline • Stress • Adjustment Disorders • Post-traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD) • Dissociative Disorders • Dissociative Identity Disorder (DID)

3. Anxiety Vs. Stress • Anxiety • A general feeling of apprehension (worry) about possible danger • Oriented to the future and more diffused than fear • Can occur in many psychopathologies • Stress • An event that creates physiological or psychological strain for the individual • Some people define stress as the body’s response to the demands of the environment • Whether you are experience stress or anxiety may depend on your sense of ______ at the moment or how well you think you can cope with the threat or challenge your are facing (e.g. Barlow, Rapee, & Reiser, 2001)

4. Categories of Stressors • Frustrations • Due to external (e.g. unemployed) or internal (e.g. physical handicaps) obstacles • Leads to self-devaluation or sense of incompetence • Pressures • Due to need to achieve goals or to behave in a particular way • e.g. to attain a high GPA (can be external or internal); to cope with job demands

5. Categories of Stressors • Conflicts • Approach-avoidance conflicts • A whether-or-not dilemma • Double-approach conflicts • Choosing between two or more desirable goals • Double-avoidance conflicts • Choosing between undesirable alternatives

6. Measuring Stress • The Social Readjustment Rating Scale • Designed by Holmes and Rahe (1967) • Asked subjects to rate various life experiences for stress impact (marriage = 500) • Total score on the scale produces the Life Change Unit (LCU) • LCU was found correlated with diseases such as heart attack (Rahn & Lind, 1971) and colds and fevers (Holmes & Holmes, 1970) • Note: correlational rather than causal relationship

7. Measuring Stress

8. Severe Stress: Catastrophic Events

9. Severe Stress: Catastrophic Events • Potential sources of trauma • Serious traffic accidents • 10% of survivors suffered from symptoms of PTSD • Plane crashes • Train/car crashes • Violence • Natural disasters • Earthquakes/tsunamis • Tornadoes/typhoons • Fires • Bomb explosions • Sexual assaults

10. The Effects of Severe Stress:General Adaptation Syndrome(p.152)

11. The Effects of Severe Stress:General Adaptation Syndrome Check also: http://www.holisticonline.com/stress/stress_GAS.htm

12. Factors Predisposing a Person to Stress (p.146) • A person’s perception of stress • Chance Vs. challenge • The individual’s stress tolerance • An individual’s learning history plays a crucial part in this general capacity to deal with stress • A person can be especially vulnerable to OR well-equipped to handle similar stressors in the future • A lack of external resources and social supports • Positive social and family relationships can moderate the effects of stress (Monroe & Steiner, 1986) • Widowed men who attended church or temple experienced less depressions than those who did not (Siegel & Kuykendall, 1990)

13. Coping with Stress (p.149) • Task-oriented coping • May involve making changes in one’s self, one’s environments, or both • Defense-oriented coping • Behavior is directly primarily at protecting the self from hurt or disorganization, rather than resolving the situation • Either: crying, repetitive talking, and mourning • Or: defense mechanisms • e.g. denial, repression, reaction formation

14. Adjustment Disorders • The disorder is the development of emotional or behavior symptoms in response to an __________ stressors • Symptoms occur within 3 months of the onset of the stressor(s) • Last for a maximum of 6 months after termination of the stressor • In excess of what would be expected from exposure to the stressor or significantly impair the individual’s functioning • The disturbance does not meet the criteria for any specific Axis I disorder • Bereavement is excluded

15. Acute Stress Disorder (ASD) • Diagnosis criteria: • Experienced, witnessed, or when confronted with a life-threatening situation and involved intense fear, helplessness, or horror • During the distressing event, exhibited the following dissociative symptoms: • Sense of numbing, detachment, apathy • A reduction in awareness of one’s surroundings • Depersonalization • Dissociative amnesia • Persistently re-experiences the trauma • Marked symptoms of anxiety, increased arousal and avoidance • Lasts for a minimum of 2 days and a maximum of 4 weeks within 4 weeks of the traumatic event

16. Dissociative Symptoms • Depersonalization • Altering of perception that causes a person temporarily to lose a sense of his or her own reality • Often a feeling of being an outside observer of one’s own behavior • How do you call this in Cantonese? • Dissociative amnesia • A psychogenically caused memory failure • Featuring the inability to recall personal information • Both, when persistent and as a dominant symptom, can become a disorder themselves

17. Post-Traumatic Stress Disorder (PTSD) • ASD lasts for a maximum of 4 weeks; if symptoms last longer, then, PTSD • Acute PTSD: duration of symptoms less than 3 months • Chronic PTSD: 3 months+ • The traumatic event is persistently reexperienced by the person • Recurring thoughts, flashback episodes or repetitive nightmares • The person persistently avoids stimuli associated with the trauma • Efforts to avoid thoughts, feelings or conversation associated with the trauma • Inability to recall an important aspect of the trauma • Decreased interest in activities

18. Post-Traumatic Stress Disorder (PTSD) • The person may experience persistent symptoms of increased arousal • Difficulty falling asleep • Irritability • Difficulty in concentrating • Hypervigilance • The individual may experience impaired concentration and memory • The person may experience feelings of depression

19. Etiology of PTSD • Risk factors • Early separation from parents • Being female - why? • Previous exposure to traumas • Biological theories • Twins studies shown a possible biological diathesis (True et al., 1993) • Higher norepinephrine level in PTSD patients • Psychological theories • Classical conditioning of fear (related stimuli as CS) • ___________ are built up and negatively reinforced by reduction of fear

20. Treatment of Stress Disorders • Medications • Antidepressants, e.g. Prozac • Crisis intervention therapy • A brief problem-focused counseling • Provide emotional support • Educating the patients about the nature of PTSD • Have patients discuss with each other as many details as they can remember • Encouraging them to describe their thoughts at the time of the event • A single debriefing session can cause more harm than helping (Mayou et al., 2000; Ehlers & Clark, 2003)

21. Treatment of Stress Disorders • Direct therapeutic exposure • Principle: fears are best reduced or eliminated by having the person confront in some fashion whatever he or she most ardently wishes to avoid • Structured exposure to trauma-related events seem better than medication • Social support • Belonging to a religious group • Empathic family members, friends or fellow traumatized individuals

22. Dissociative Disorders (p.278) • Dissociative Disorders appear mainly to be ways of avoiding anxiety and stress and the person’s usual coping resources • Characterized by changes in a person’s sense of identity, memory, or consciousness • Individuals may be unable to recall important events or may temporarily forget their identity or even assume a new identity • They may wander far from their usual surroundings

23. Dissociative Disorders • Dissociative Amnesia is the inability to recall important personal information • Dissociative Fugue involves extensive memory loss, including one’s identity • Depersonalization Disorder involves an alteration of a person’s self-experience • Dissociative Identity Disorder (DID) involves the presence of two different identities (alters)

24. Dissociative Identity Disorder (p.298) • Major and common features of DID • formerly called Multiple Personality Disorder (MPD) • Characterized by having two or more distinct identities (alters) • These different personalities (alters) may have distinct characteristics which usually have their own names, ways of dressing or speaking, different handedness or wear glasses of different prescriptions • The alters can be unaware of one another or may be in conflict • Some alters/identities may be more salient, while the primary identity (with the individual’s real name) tends to be passive, carrying guilt and emotional burden for the rest

25. DID • Some interesting features of DID • Many patients have at least one impulsive alter who handles sexuality and generates income, sometimes by acting as a prostitute • Number of alters can range from an average of 2 or 3 to a hundred • Cross-gendered alters are not uncommon • The transition from one personality to another is called a switch and is usually instantaneous • Some experiments demonstrated interpersonality amnesia (see Kihlstrom, 2001) while some researchers doubt it (e.g. Huntjens et al., 2002) • Some studies confirm that various alters have unique psychophysiological profiles (e.g. Putnam, 1997)

26. DID • Course of DID • Usually begins in childhood • More common in women than in men • Early presenting symptoms of DID involves lapses of memory accompanied by changes in environment that cannot be explained • New alters may emerge in response to new life situations

27. DID • Continuing controversy in diagnosis of DID • Only one-third of psychiatrists reported no reservation about inclusion of DID in DSM-IV (Pope et al., 1999) • Cases before 70’s were rare • In 1973, Sybil was published and followed by a dramatic increase in DID • Some therapists were criticized for suggesting strongly to clients that they had DID, sometimes with the aid of hypnosis • It was also used by defendants and their lawyers to escape punishment for crimes (“My other personality did it.”)

28. Causal Factors in Dissociative Disorders • _______ is generally accepted as a causal factor in Dissociative Disorders • Etiology of DID • Biological factors • unclear • The child abuse pathway • A child’s attempt to cope with an overwhelming sense of hopelessness and powerlessness in repeated traumatic abuse • The childhood neglect pathway • e.g. left unattended over long periods of time • The iatrogenic pathway (treatment induced) • The factitious pathway

29. Reported Childhood Abuse in 5 Separate Studies of DID Patients

30. Documented Childhood Abuse in 12 Cases of DID Among Convicted Murderers

31. Treatment and Outcomes in DID • Psychoanalytic therapy seeks to lift repressed memories • The use of hypnosis is controversial • Goal of therapy for DID is to • Identify cues or triggers that provoke memories of trauma and/or dissociation and to neutralize them • Work through the trauma and resolution of dissociative defenses • Integrate the several personalities, not the elimination of extra alters • Help each alter understand that he or she is part of one person • Treat the alters with fairness and empathy • Limited evidence on effectiveness of medication • Prognosis is ________