Dissociative symptoms of PTSD: Assessment and treatment implications · 2016-09-30 · PTSD: Assessment and treatment implications JENNIFER STEWARD, M.A. AND ELANA NEWMAN, PH.D. ...

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