Post on 17-Jun-2020
Dissociative symptoms of PTSD: Assessment and treatment implications JENNIFER STEWARD, M.A. AND ELANA NEWMAN, PH.D.
DECEMBER 10 TH 2014
Learning Objectives
o Describe the dissociative symptoms of PTSD
o Differentiate dissociative symptoms and subtype
o Discuss assessment considerations
o Identify treatment strategies and considerations
Defining Dissociation o “Partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements”- ICD-10
World Health Organization, 1991
Memory
Consciousness Personal Identity
Dissociation in Psychopathology
o Dissociative Disorders
oTrauma-related Disorders
oPsychotic Disorders
Spitzer, Barnow, Freyberger, & Grabe, 2006
Intrusion
• Intrusive memories
•Nightmares
•Dissociative reactions (e.g., flashback)
•Upset at reminders
•Physical reactions to cues
Avoidance
•Avoids memories, thoughts, feelings
•Avoids external reminders
Negative Cognitions & Mood
• Inability to recall
•Exaggerated negative belief about oneself, others, or world
•Distorted blame
•Negative emotional state
•Detached/ distant
• Inability to experience positive emotions
Arousal
•Difficulty falling/ staying asleep
• Irritability or anger
•Difficulty concentrating
•Hypervigilance
•Exaggerated startle response
•Reckless or self-destructive behavior
PTSD Symptoms
American Psychiatric Association, 2013
Dissociative and Intrusion
o DSM Criterion B Symptoms o Dissociative reactions in which the
individual feels or acts as if the traumatic event(s) were recurring.
o Typically manifest as flashbacks
o Occur on a continuum
American Psychiatric Association, 2013
Dissociative Specifier o Depersonalization - persistent
or recurrent experiences of feeling detached from oneself, as if one were an outside observer
o Derealization - persistent or recurrent experiences of unreality of surroundings (e.g., the world is experienced as unreal, dreamlike, distant or distorted).
American Psychiatric Association, 2013
Dissociative Specifier oAccording to the National Center for PTSD, patients with the dissociative subtype of PTSD showed: oRepeated traumatization and early adverse experiences
o Increased psychiatric comorbidity
o Increased functional impairment
o Increased suicidality
www.ptsd.va.gov
Differentiating Dissociation
• Re-experiencing
• Flashbacks
• Undermodualtion of emotion
Dissociative Symptoms
• Depersonalization
• Derealization
• Overmodulation of emotion
Dissociative Subtype
Lanius et al., 2010
Assessment Considerations
Assessment Tools o Interviews o Clinician Administered PTSD Scale-5 (CAPS-5)
o Structured Clinical Interview for DSM-IV® Dissociative Disorders (SCID-D-R)
o Self-Report o PTSD Checklist for DSM-5 (PCL)
o Dissociative Experiences Scale (DES)
o Multiscale Dissociation Inventory (MDI)
Clinical Questions o Flashbacks o “Do you ever feel like the [trauma] is still happening to you?”
o “Do you ever hear the sound of the [gunshot, accident, other trauma]?”
o Depersonalization o “Do you ever feel like you are outside your body?”
o “Do you ever feel like you are watching things that happen to you from outside yourself?”
o Derealization o “Do you ever feel like you are living in a dream or movie?”
o “Do you ever feel like people and things around you are not real?”
Briere & Scott, 2014
PTSD vs. Psychotic Symptoms
Briere & Scott, 2014; American Psychiatric Association, 2013
Flashbacks Hallucinations
PTSD vs. Dissociative Disorders
Dissociative Symptoms
Trauma Exposure
Comorbid Disorders
Trauma Exposure
Dissociative Symptoms
PTSD with dissociative
subtype
Treatment Considerations
Grounding Techniques
Najavits, 2002
Describe the environment
Imagine doing something in depth
Counting, saying the alphabet, categories
Mental
Touching things around you
Use of cool or warm items
Grounding feet into the floor
Physical
Favorite things
Visualizing safe place
Coping statement
Soothing
Treatment Considerations o General therapeutic considerations
o Inability to engage in the treatment process
o Difficulty building rapport
o Exposure based treatments o Impeded fear activation
o Higher dissociative symptoms worse treatment outcomes (Resick et al., 2012)
o Dissociation did not predict poorer treatment response (Hagenaars, , van Minnen, & Googduin, n.d)
o Emotion regulation treatments o Recent studies have examined sequenced treatments that first focus on emotion
regulation skills (Cloitre et al., 2012)
o Skill Training in Affect and Interpersonal Regulation (STAIR)
Conclusion
o Describe the dissociative symptoms of PTSD
o Differentiate dissociative symptoms and subtype
o Discuss assessment considerations
o Identify treatment strategies and considerations
Questions?
References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arlington, VA: American Psychiatric Publishing Briere, J., & Scott, C. (2014). Principles of trauma therapy: A guide to symptoms, evaluation, and
treatment, 2nd edition, DSM-5 update. Thousand Oaks, CA: Sage. Cloitre, M., Petkova, E., Wang, J., and Lu (Lassell), F. (2012). An examination of the influence of a
sequential treatment on the course and impact of dissociation among women with PTSD related to childhood abuse. Depression and Anxiety, 29, 709-717. doi:10.1002/da.21920
Hagenaars, M. A., van Minnen, A., & Googduin, K. L. (n.d). The impact of dissociation and depression on the efficacy of prolonged exposure treatment for PTSD. Combat and Operational Stress Research Quarterly. p. 2. doi:10.1037/e717692011-004.
Lanius, R.A., Vermetten, E., Loewenstein, R.J., Brand, B., Schmahl, C., Bremner, J.D., and Spiegel, D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167, 640-647. doi:10.1176/appi.ajp.2009.09081168
Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. Guilford substance abuse series. New York, NY, US: Guilford Press
Resick, P.A., Suvak, M.K., Johnides, B.D., Mitchell, K.S., and Iverson, K.M. (2012). The impact of dissociation on PTSD treatment with cognitive processing therapy. Depression and Anxiety, 29, 718-730. doi:10.1002/da.21938
Spitzer, C., Barnow, S., Freyberger, H. J., & Grabe, H. J. (2006). Recent developments in the theory of dissociation. World Psychiatry, 5(2), 82–86.
World Health Organization. (1991). The ICD-10 classification of mental and behavioural disorders. Clinical
descriptions and diagnostic guidelines. Geneva: World Health Organization.
Photo References • http://www.hopestreetcentre.co.uk/therapy-help-sandbach-cheshire/dissociation
•http://www.psychologytoday.com/blog/the-search-self/201205/hope-disappointment-being-diagnosed-dpd
•http://consciousnessofreality.blogspot.com/2013/05/derealization.html