Trauma and Stress Related Disorders & Dissociative Disorders

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2 Trauma and Stress Related Disorders & Dissociative Disorders Sarah Reed, MD & Jason Roof, MD University of California Davis Department of Psychiatry and Behavioral Science

3 Disclosures Disclaimers & Accolades Audience Participation Instructions

4 DISORDERS USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD, OR ADOLESCENCE (DUFDICA) ANXIETY DISORDERS DISSOCIATIVE DISORDERS ADJUSTMENT DISORDERS DSM IV-TR

5 ANXIETY DISORDERS OBSESSIVE- COMPULSIVE AND RELATED DISORDERS (OCaRD) TRAUMA AND STRESSOR RELATED DISORDERS (TaSRD)

6 DUFDICA (36) NEURO- DEVELOPMENTAL DISORDERS (20) ANXIETY DISORDERS (11) OCaRD ANXIETY DISORDERS (9) (14) TaSRD (7) DD (5) DD (5)

7 TRAUMA AND STRESSOR RELATED DISORDERS Reactive Attachment & Disinhibited Social Engagement Adjustment Disorders Acute Stress Disorder Post Traumatic Stress Disorder Other & Unspecified Disorders

8 REACTIVE ATTACHMENT DISORDER Experienced a pattern of trauma Inhibited, emotionally withdrawn Social and emotional disturbance

9 REACTIVE ATTACHMENT DISORDER CASE STUDY Son of abusive alcoholic, frequently homeless Resists being civilized by caregivers Extreme measures to escape caregivers Bouts of loneliness, difficulty empathizing

10 DISINHIBITED SOCIAL ENGAGEMENT DISORDER Experienced a pattern of trauma Approaches and interacts with unfamiliar adults phenotype more closely resembling ADHD

11 DISINHIBITED SOCIAL ENGAGEMENT CASE STUDY Kidnapped from Africa Near-drowning Housed in a zoo then with his kidnapper Pattern of engaging in dangerous situations

12 DISINHIBITED SOCIAL ENGAGEMENT CASE STUDY 2 Abusive father, later orphaned Social outcast, then banished from village Seeks out relationships without social reciprocity Poor judgment of intentions of others

13 ADJUSTMENT DISORDERS DSM IV Own Chapter Subthreshold Diagnosis

14 ADJUSTMENT DISORDERS DSM IV Own Chapter Subthreshold Diagnosis DSM 5 Part post-stress family Stress-response syndrome

15 DSM IV ACUTE STRESS DISORDER Filled diagnostic pre-ptsd gap Clustered Symptoms Emphasized dissociation

16 DSM IV ACUTE STRESS DISORDER DSM 5 Filled diagnostic pre-ptsd gap Clustered Symptoms Emphasized dissociation Not linked to PTSD 9 of 14 symptoms, not clustered Dissociation not required

17 Dr. Roof gives overview of history and changes to PTSD!

18 Posttraumatic Stress Disorder Stress Disorder

19 Soldier s heart IRRITABLE heart

20 Shell shock

21 Posttraumatic Stress Disorder

22 November 28, 1942

23 increased nervousness fatigue nightmares

24 integrate this Boston nightclub Nov 28, 1942 deadliest nightclub fire in U.S. history 492 people killed Main entrance was a single revolving door Side doors bolted shut (to prevent leaving without paying) Other doors opened inwards

25 POSTTRAUMATIC STRESS DISORDER Overview of Changes from DSM-IV to DSM-5 No longer an Anxiety Disorder Trauma- and Stress-or-Related Disorders Traumatic events more defined Removed intense fear, helplessness or horror Not useful in determining onset of PTSD

26 DISORDER or INJURY? Military concern Disorder increases stigma Mental health Military environment needs to change Injury may be too imprecise

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28 Actual or threatened death Serious injury OR Sexual violence EXPOSURE

29 MEANS OF EXPOSURE Direct Witnessing, in person Learning that it occurred (close friend or close family member only) Repeated/ extreme exposure

30 MEANS OF EXPOSURE Repeat/ extreme exposure (A4) DOES NOT apply to exposure through media (Unless work related)

31 POSTTRAUMATIC STRESS DISORDER Reexperiencing Avoidance FOUR Diagnostic Clusters Negative cognitions and mood Arousal

32 RE-EXPERIENCING/ INTRUSION SYMPTOMS (B) Intrusive distressing memories Dreams Dissociative reactions (flashbacks) Psychological distress to exposure of cues Physiological reactions to cues

33 AVOIDANCE (C) Avoid memories, thoughts or feelings Avoid external reminders that arouse memories, thoughts or feelings

34 NEGATIVE ALTERATIONS IN COGNITIONS AND MOOD (D) Can t remember important aspects of event Persistent/ exaggerated negative beliefs or expectations (self or world) Distorted cognitions leading to blame self/others Persistent negative emotional state Diminished interest/ participation Detachment from others Inability to experience positive emotions

35 AROUSAL(E) Irritable behavior/ angry outbursts Reckless or self-destructive behavior Hypervigilance Exaggerated startle Problems with concentration Sleep disturbance

36 POSTTRAUMATIC STRESS Disturbance to continue for more than a month Not another cause No more distinction between acute and chronic phases of PTSD DISORDER

37 With dissociative symptoms Depersonalization Derealization PTSD SPECIFIERS

38 GET OUT OF HERE YOU KIDS! Exclusion of children 6 and younger?? You have your own criteria!

39 Posttraumatic Stress Disorder 60% of males/ 50% of females experience significant trauma Lifetime prevalence of PTSD is 6%

40 Posttraumatic Stress Disorder Predisposing Vulnerability Factors Childhood trauma Personality disorder traits (Borderline, paranoid, dependence, antisocial) Poor support system Female Genetic vulnerability to psychiatric illness Recent stressful life changes External locus of control nature) vs manmadeexcessive alcohol intake

41 Posttraumatic Stress Disorder Most important factors... Severity of trauma Duration of trauma Proximity to traumatic event

42 Acute Stress Disorder A cute (baby/ young) PTSD PTSD symptoms occurring within 4 weeks of trauma stops 2 to 4 weeks after

43 PTSD Borderline PD Dissociative Symptoms Social Withdrawal Feeling Permanently Damaged Guilt AH Irritability/ Anger Impaired Relationships Chronic feelings of emptiness Unstable selfimage Disorganized Attachment Vulnerability to re-victimization MDD Hopelessness Self-hate Suicidal Ideation Complex-PTSD or DESNOS Adapted from Resnick, 2012

44 Dr. Roof gives overview of changes to Dissociative Disorders THEN Dr. Reed then gives new changes to DID in DSM5!

45 CHANGES TO DISSOCIATIVE DISORDERS Derealization included in name/ Increased Arousal symptom structure of was had beencalled depresonalization disorder Dissociative fugue is now a specifier of dissociative amnesia (no longer separate)

46 CHANGES TO DISSOCIATIVE IDENTITY DISORDERS DID changes Increased Arousal o Disruption of identity may now be reported o Memory gaps may occur in everyday events not just traumatic events o Pathological possession in some cultures included

47 DEBATE! Yes No

48 I. Opening statements (3 minutes each) II. Audience questions (5 minutes) III. Closing Statements (2 minutes each)

49 I. Opening statements (3 minutes each) II. Audience questions (5 minutes) III. Closing Statements (2 minutes each)

50 MULTIPLE PERSONALITY DISORDER/ DISSOCIATIVE IDENTITY DISORDER

51 DOCUMENTED CASES of DID Sybil published 1976 Sybil (film) released ,000 cases

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53 HILLSIDE STRANGLER

54 HILLSIDE STRANGLER Judge opined he was going to put him in jail, throw away the key and let the other personalities do as they wished

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59 I. Opening statements (3 minutes each) II. Audience questions (5 minutes) III. Closing Statements (2 minutes each)

60 I. Opening statements (3 minutes each) II. Audience questions (5 minutes) III. Closing Statements (2 minutes each)

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62 Does DID belong in the DSM? Yes No

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65 Trauma and Stress Related Disorders & Dissociative Disorders Sarah Reed, MD Jason Roof, MD University of California Davis Department of Psychiatry and Behavioral Science